JP2021526507A - Compositions and Methods for Treating Sudden Death Induced by Seizures - Google Patents

Abstract

5-HT receptor agonists are useful in the treatment of various diseases. Provided herein are methods of reducing the incidence and / or severity of seizures in human patients, using, for example, 5-HT receptor agonists such as 5-HT4 agonists (eg, fenfluramine). be. How to treat epilepsy or epileptic encephalopathy in subjects diagnosed with epilepsy and / or reduce the incidence of SUDEP by administering 5-HT4 agonists (eg, fenfluramine) to subjects in need. Provides a way to improve or eliminate. Pharmaceutical compositions for use in practicing the methods of the invention are also provided.

Description

The present invention generally relates to the therapeutic treatment of patients diagnosed with paroxysmal disorders such as epilepsy or epileptic encephalopathy. More particularly, the present invention is the use of fenfluramine as therapeutic agents, as well as unexpected sudden death patients with epilepsy induced by diagnosed with intractable type of epilepsy or epileptic encephalopathy and seizures (S UDDEN U nexpected D eath in Ep ilepsy; SUDEP) their use for treating human patients having a risk of about.

Epilepsy is a condition of the brain characterized by susceptibility to recurrent seizures. Epilepsy includes birth trauma, perinatal infections, anoxia, infectious diseases, toxin intake, brain tumors, hereditary or degenerative diseases, head injuries or trauma, metabolic disorders, cerebrovascular attacks and There are many causes, including non-limiting alcohol withdrawal.

Numerous subtypes of epilepsy have been characterized, each with its own clinical symptoms, signs and phenotypes, underlying pathophysiology and distinct responses to different treatments. The system adopted by the International Antiepileptic Federation (“ILAE”) Classification and Terminology Committee is up-to-date and widely accepted in the art (eg Berg et. Al,'' Revised terminology and concepts for). See organization of seizures,'' Epilepsia, 51 (4): 676-685 (2010)).

(Table 1) ILAE classification scheme for epilepsy subtypes

Part V of the ILAE classification scheme states that there are still subtypes of epilepsy or epileptic encephalopathy whose list is far from complete and has not yet been fully characterized or recognized as a separate syndrome. Emphasizes the facts. That is, one of ordinary skill in the art would have different subtypes of epilepsy induced by different stimuli, controlled by different biological pathways, and genetic, environmental, and / or brain disease or damage. You will understand that whatever the cause is, it has a different cause. That is, one of ordinary skill in the art will appreciate that the teachings of one epilepsy subtype do not necessarily apply to any other subtype.

Of particular importance is the large number of compounds used to treat different types of epilepsy or epileptic encephalopathy, with different subtypes of epilepsy or epileptic encephalopathy responding differently to different anticonvulsants. That is, certain drugs may be effective against one type of epilepsy, but may be completely ineffective against other types, or because of exacerbation of symptoms such as worsening seizure frequency and severity. Can even be contraindicated. As a result, the efficacy of certain drugs for certain types of epilepsy is completely unpredictable, and therefore certain drugs previously unknown to be effective for certain types of epilepsy or epileptic encephalopathy. If found to be valid, this is a totally surprising finding. This is especially true for epilepsy syndrome, which was previously refractory and resistant to known drugs.

A number of different drugs have been used in the treatment of various types of epilepsy or epileptic encephalopathy. The list below is not comprehensive, but may include drugs that are widely prescribed to patients diagnosed with epilepsy.

(Table 2) Commonly prescribed antiepileptic drugs

Because different subtypes of epilepsy or epileptic encephalopathy respond differently to different anticonvulsants, it is in any case that a particular drug is effective against a particular type of epilepsy or epileptic encephalopathy. It's an amazing result.

Dravet syndrome is a rare and disastrous type of intractable epilepsy that begins in infancy. First, the patient experiences a long-term seizure. In the second year, more types of seizures begin to occur, which coincide with developmental decline or stagnation, probably due to repeated cerebral hypoxia due to continuous seizures. This causes poor development of language and motor skills. Children with Dravet syndrome are more likely to experience multiple seizures daily. Epileptic seizures are much more likely to result in death in patients with Dravet syndrome; about 10-15% of patients diagnosed with Dravet syndrome die in childhood, especially between the ages of 2 and 4. In addition, patients are at risk for many related conditions, including orthopedic developmental problems, failure to thrive and chronic upper respiratory tract infections. Children with Dravet syndrome require constant management, and many require institutionalization when they reach their teens, so treatment costs are high.

The symptoms and diagnosis of Dravet syndrome are significantly different from other types of epilepsy. Ceulemans states that Dravet syndrome can be distinguished from other types of epilepsy in the following ways: "The appearance of tonic-clonic seizures by the age of one, followed by myoclonic and ataxia, seizures" Later psychomotor seizures, as well as poor response to antiepileptic drugs. ”(Ceulemans, Developmental Medicine & Child Neurology, 2011, 53 (Suppl.2): 19-23).

Brunklaus et al. (BRAIN, 2012, 135: 2329-2336) also observed: "Dravet syndrome is typically a child who no longer has developmental problems and is 1 year old. Present by long-term febrile and afebrile, with general or half-clonic epileptic seizures. Other seizure types, including myochrony, focal and atypical demimetics, appear between 1 and 4 years of age (Dravet, 1978). "

Therefore, the symptoms and diagnosis of Dravet syndrome are significantly different from other types of epilepsy. Therefore, given its characteristic clinical properties, one of ordinary skill in the art will find it clear that any particular compound is effective in Dravet syndrome, or have just reason to presume that way. Will not.

Dravet is also characteristic of its genetic aspects. It is known in the art that a mutation in the alpha subunit of a neuron-specific potential-opening sodium channel (SCN1a) was discovered in 2001 as a major genetic cause of Dravet syndrome (Ceulemans, Developmental Medicine & Child). Neurology, 2011, 53 (Suppl.2): 19-23; Brunklaus et. Al, BRAIN, 2012, 135: 2329-2336). Therefore, the causes of Dravet syndrome are significantly different compared to other types of epilepsy. Moreover, unlike other types of epilepsy, Dravet's diagnosis is based in part on the detection of these gene mutations in addition to clinical findings. As a result, with the advent of improved genetic testing, the number of patients diagnosed with this disease is increasing.

It is of particular concern that children with Dravet syndrome are particularly susceptible to episodes of status epilepticus. This severe and refractory condition is typically classified as a medical emergency that requires immediate medical intervention with hospitalization. Status epilepticus can be fatal. It can also be associated with cerebral hypoxia, possibly leading to damage to brain tissue. Frequent hospitalization of children with Dravet syndrome is clearly distressing not only for the patient, but also for the family and caregivers.

Also of concern to people living with epilepsy is the risk of unexpected sudden death (SUDEP) in epilepsy patients. SUDEP refers to the death of people with epilepsy, not due to injury, drowning, or other known causes. Estimates vary, but some studies suggest that approximately 1.16 cases of SUDEP are found in every 1,000 people with epilepsy each year. Most, if not all, cases of SUDEP occur during or shortly after a seizure, and although the exact cause is unknown, the following is a list of factors that may play a role:
Breathing. Seizures can cause respiratory arrest in humans due to apnea or airway obstruction. If these pauses last too long, blood oxygen can be reduced to life-threatening levels. Mind rhythm. Seizures can also cause dangerous heart rhythm or even heart failure. Other causes and mixed causes. SUDEP can occur due to multiple causes or combinations, including both dyspnea and abnormal cardiac rhythm.

Three drugs that are particularly effective for partial attacks are vigabatrin, a selective and irreversible GABA transaminase inhibitor that significantly increases global levels of GABA; a potent inhibitor of GABA uptake into neurons and glial cells. There is tiagabine; as well as Na ⁺ -dependent and / or Ca ²⁺ -dependent alteration of the activity potential ^{, enhanced GABA-mediated Cl-} flow to neurons, and kainic acid-mediated conductance in AMPA / kainate-type glutamate receptors. It is a topiramate that is thought to produce its antiepileptic effect through several mechanisms, including inhibition of. (Aengehagen, et al., 2003, Neurochemical Research, 28 (2): 333-340).

Several anticonvulsant therapies have been used to reduce seizure cases in patients with Dravet syndrome, but the results obtained with such therapies are typically poor, and those therapies are at best partial seizures. It only affects the outage. In general, seizures associated with Dravet syndrome are typically resistant to conventional treatment, and anticonvulsants that act through blocking of sodium channels exacerbate Dravet syndrome seizures. In addition, many anticonvulsants such as clobazam and clonazepam have unwanted side effects, especially in pediatric patients.

Recently, refractory seizures characteristic of Dravet syndrome have been significantly reduced in frequency and / or severity by administration of a drug called 3-trifluoromethyl-N-ethylamphetamine (“fenfluramine”). It has been discovered that, in some cases, it can disappear completely. See Ceulemans et al., Successful use of fenfluramine as an add-on treatment for Dravet Syndrome, Epilepsia 53 (7): 1131-1139, 2012. Fenfluramine is an amphetamine derivative having the following structure.

Fenfluramine is a racemic mixture of the two enantiomers dexfenfluramine and levofenfluramine and has been reported to increase circulating levels of serotonin, a neurotransmitter that regulates mood, appetite and other functions. ..

Serotonin (also known as "5-hydroxytryptamine" or "5-HT") is a monoaminergic neurotransmitter that is thought to regulate many sensory, motor and behavioral processes in the mammalian nervous system. These diverse responses are elicited through activation of a large family of receptor subtypes. Of the many subtypes of serotonin receptors, the 5-HT _1B and 5-HT _2C subtypes are said to be most strongly involved in feeding and body weight regulation, and these receptors are involved in food intake regulation. It is expressed in possible hypothalamic regions. Fenfluramine is known to have high affinity for and be active in 5-HT2A, 5-HT _2B and 5-HT _2C receptor subtypes (Rothman et al., 2015), 5 -Fenfluramine is co-administered with phentermine as part of a common weight loss drug combination therapy marketed as fenfluramine (ie, phenfluramine / phentermine) because the _{HT 2C agonist induces appetite suppression.} By doing so, it was used to treat obesity. Fenfen was first marketed in the United States in 1973 to prevent and treat obesity, but the use of fenfen was associated with the development of valvular heart disease and pulmonary hypertension, so it was marketed in the United States and the world in 1997. Withdrew from.

The side effects associated with the use of fenfluramine as an appetite suppressant are thought to be due to the interaction of _{norfenfluramine, the major metabolite of fenfluramine, with the 5-HT 2B receptor of 5-HT 2B} . Activation was associated with valvular heart disease. This is why Fen Fen has withdrawn from the market and is no longer shown for use in any therapeutic area.

Despite past concerns about cardiovascular safety that arose when high doses of fenfluramine were used in the treatment of adult obesity, with potential therapeutic benefits and known cardiovascular risks of fenfluramine. Attempts have been made to identify further therapeutic uses for the product while comparing and examining. One disorder in which new treatment options are in great need is epilepsy or epileptic encephalopathy.

Although several antiepileptic drugs have been developed, about one-third of epilepsy patients are refractory to treatment. Therefore, the search for new mechanisms and drugs that can regulate cell excitability continues.

Historically, studies of the efficacy of fenfluramine in patients with epilepsy have been a general paradigm, namely that the main effect of fenfluramine is in the behavior of causing or inducing seizures, treating or preventing the seizures themselves. It led to a paradigm of not being a thing. For example, Aicardi and Gastaut (New England Journal of Medicine (1985), 313: 1419 and Archives of Neurology (1988) 45: 923-925) have self-induced photosensitive epilepsy, that is, the patient intentionally brightens the light or the sun. We reported four cases of seizures caused by staring and found that these seizures responded to treatment with fenfluramine. Similarly, in Epilepsy Research (1988) 2: 340-343, Clemens described seizure-induced compulsive behavior in patients with seizures induced by pattern hypersensitivity that were resistant to anticonvulsant treatment. We report a case study treated with fenfluramine for suppression. Fenfluramine reportedly successfully terminated these self-induced seizures. Clemens said that this was because fenfluramine blocked the photosensitive epilepsy mechanism, secondarily by reducing the pathogenic urge to seizure-inducing behavior / coercion, i.e. treating the seizure itself. I concluded that it was not a thing.

In Neuropaediatrics, (1996); 27 (4): 171-173, Boel and Casaer reported on a study of the effects of fenfluramine in children with refractory epilepsy, all showing seizure-induced compulsive behavior. They observed that administration of fenfluramine at a dose of 0.5-1 mg / kg / day reduced the number of seizures experienced by patients, saying, "This drug is a young person with idiopathic disease or symptomatic generalized epilepsy. It may have significant antiepileptic activity in patients, i.e. selected groups of children with self-induced seizures. " The authors wrote that "fenfluramine does not have direct antiepileptic activity, but may act through its effect on seizure-inducing obsessive-compulsive impulses." Therefore, the authors suggested that fenfluramine affects behavior rather than the seizure itself.

In a brief journal report (Epilepsia, 43 (2): 205-206, 2002) published in Epilepsia, Boel and Casaer described fenfluramine therapeutically in patients with refractory epilepsy and self-induced seizures. Said that there seems to be a benefit. However, the authors did not attribute the effectiveness of fenfluramine to generalized anticonvulsant activity.

Another type of epilepsy that can be treated with fenfluramine is Lennox-Gastaut syndrome (LGS). LGS was first described in 1960 and is named after the neurologists William G. Lennox (Boston, USA) and Henri Gastaut (Marseille, France). This is a difficult type of childhood-onset epilepsy that most often appears between the ages of 2 and 6, but can occur earlier or later. LGS is characterized by high frequency seizures and different seizure types; typically with developmental delay and psychological and behavioral problems. In children, common causes of LGS include perinatal brain damage, brain malformations such as tuberous sclerosis or cortical dysplasia, CNS infections, and degeneration or metabolic disorders of the nervous system.

In LGS, several different types of seizures are typical each day. Equally typical are widespread seizures that can occur. The most common types of seizures are tonic-axial, weakness, and absence seizures, but myoclonus, generalized tonic clonic, and focal epilepsy can also occur in any LGS patient. Weakness, atypical absence seizures, tonicity, focus, and tonic-clonic seizures are also common. In addition, many LGS patients will develop status epilepticus, often characterized by dizziness, apathy, and no response. In addition, most patients suffer from atonic seizures, also known as atonic seizures, which can cause muscle weakness and sudden and unexpected falls, often causing serious injuries, preventing patients from head injuries. That's why you often wear a helmet to get injured.

In addition to multiple daily seizures of various types, children with LGS often have arrest / delay in psychomotor development and behavioral disorders. The syndrome is also characterized by specific findings in electroencephalography (EEG), especially spike-and-wave complex during interictal periods (ie, during seizures) and fast wave activity during sleep.

The optimal treatment for LGS has not yet been established. Currently, various therapeutic approaches are used in LGS, including conventional antiepileptic drugs, diet and surgery, but evidence supporting these treatments is weak and treatment remains ineffective in most cases. The use of some common first-line treatments is based on clinical experience or conventional knowledge; examples include broad-spectrum anticonvulsants such as valproic acid and benzodiazepines, most often clonazepam and clobazam. Is done. A few drugs have been shown to be effective in some patients of a particular seizure type by a double-blind, placebo-controlled trial; examples include clobazam, lamotrigine, topiramate, felbamate, and rufinamide. However, most patients continue to have serious attacks while taking these drugs. Currently used second-line drugs such as zonisamide are prescribed based on the results of several open-label, uncontrolled trials. A ketogenic diet may be useful in patients with LGS who are refractory to medical treatment. Surgical options for LGS include corpus callosotomy (for involuntary seizures), vagal nerve stimulation, and local cortical resection (in the presence of a single resectable lesion). However, it should be noted that significant improvements from any of these therapies alone or in combination rarely occur.

Despite the severity of LGS symptoms and how often they occur (accounting for up to 10% of all childhood epilepsy), there is currently no standard evidence-based treatment for this disease. A comprehensive review of the literature [see Hancock EC & Cross JH, Treatment of Lennox-Gastaut syndrome (Review), published in The Cochrane Library 2013, Issue 2] evaluated nine randomized pharmaceutical treatments for this syndrome. I just found a control trial. The authors conclude that there is a lack of research and "no monotherapy has been found to be very effective for this syndrome (to date)." Same as above, p.12. The authors further concluded that "optimal treatment for LGS remains uncertain and no previous study has shown that any drug is very effective." Same as above, p.12.

Fenfluramine is promising in the treatment of certain epilepsy and / or epileptic encephalopathy. Lagae et al.,'' Add-on Therapy with Low Dose Fenfluramine (ZX008) in Lennox Gastaut Syndrome'' Abstract 3.366, 2016 presented at AES 2016 Annual Meeting in Houston, Tx Present the results of a one-center Phase 2 pilot open-label dose study; text and drawings are available below: https://www.aesnet.org/meetings_events/annual_meeting_abstracts/view/240065); also USA See also Patent Application No. 15 / 246,346.

Therefore, the need for effective therapeutic agents to treat, prevent or ameliorate frequent and severe seizures in patients with refractory epilepsy syndrome is urgent, long-standing and yet unmet. .. The present disclosure has applicability for a range of different types of epilepsy and epilepsy subtypes, including Dravet syndrome, Doose syndrome, epileptic spasms, West syndrome and Lennox-Gastaut syndrome.

Summary The methods disclosed herein are generally useful in treating, preventing or ameliorating the symptoms associated with paroxysmal disorders in patients in need of such treatment. For example, the methods disclosed are refractory seizures in which conventional antiepileptic drugs are inadequate, ineffective, or contraindicated, including, but not limited to, Dravet syndrome, Lennox-Gastaut syndrome, Doose syndrome, epileptic spasms, and West syndrome. It is useful for preventing, treating or ameliorating the symptoms associated with the disorder.

In some aspects, what is provided herein is a method of reducing the frequency or severity of unexpected sudden death (SUDEP) in patients with seizures or epilepsy in human patients, with 5-hydroxytryptamine receptor. The stage of administering a therapeutically effective dose of a body 4 agonist (5-HT ₄ agonist) to the patient, and the 5-HT ₄ agonist stimulating the patient's 5-HT ₄ receptor, thereby causing the patient's seizures. The method comprising reducing the incidence, frequency or severity.

In some aspects, what is provided herein is a method of inhibiting attack-induced respiratory arrest (S-IRA) in a human patient, wherein a therapeutically effective dose of _{a 5-HT 4 agonist is used.} The method comprising administering to the patient and stimulating the patient's 5-HT _{4 receptor with a 5-HT 4} agonist thereby inhibiting the patient's S-IRA.

In some aspects, what is provided herein is a method of reducing the average length of post-attack suppression (PID) duration in a human patient, the therapeutically effective dose of _{a 5-HT 4 agonist.} The method comprises the steps of administering to the patient and thereby stimulating the patient's 5-HT _{4 receptor with a 5-HT 4} agonist, thereby inhibiting the patient's PID period.

In some aspects, what is provided herein is a method of reducing the likelihood of unexpected sudden death (SUDEP) in a patient with epilepsy induced by a seizure in a human patient, a 5-HT ₄ agonist. The method comprising administering to the patient a therapeutically effective dose of the patient and thereby stimulating the patient's 5-HT _{4 receptor with a 5-HT 4} agonist, thereby reducing the accuracy of the patient's SUDEP. Is.

In some aspects, what is provided herein is one or more 5-HT in the brain of a patient diagnosed as having the potential for seizure-induced epilepsy patient death (SUDEP). ₄ a method of stimulating the receptor, the patient showed seizures, the method, 5-HT ₄ stages administering agonist effective dose to the patient, and 5-HT ₄ agonist of the patient 5 The _{method comprising stimulating the HT 4} receptor thereby reducing the likelihood of SUDEP in the patient.

In some embodiments of the method, 5-HT ₄ agonists are fenfluramine, BIMU-8, cisapride, mosapride, prucalopride, lenzaprid, RS-67506, tegaserod, zacopride, metoclopramide, and sulpiride or pharmaceutically acceptable thereof. Selected from the group consisting of salts.

In some embodiments of the method, the 5-HT ₄ agonist is fenfluramine, or a pharmaceutically acceptable salt thereof.

In some embodiments, fenfluramine is administered as an adjunctive therapeutic agent.

In some embodiments, the therapeutically effective dose of fenfluramine is selected from the group consisting of 0.2 mg / kg / day to 0.08 mg / kg / day up to a maximum daily dose of 30 mg.

In some embodiments of the method, the therapeutically effective dose of fenfluramine is 0.8 mg / kg / day to 0.01 mg / kg / day.

In some embodiments of the method, a therapeutically effective dose of fenfluramine is administered in a dosage form selected from the group consisting of oral, injection, transdermal, inhalation, nasal, rectal, vaginal and parenteral.

In some embodiments of the method, a therapeutically effective dose of fenfluramine is administered in oral liquid dosage form.

In some embodiments, the method further comprises administering to the patient an effective dose of stiripentol or a pharmaceutically acceptable salt thereof.

In some embodiments, the method further comprises administering to the patient an effective dose of valproate or a pharmaceutically acceptable salt thereof.

In some embodiments, the method further comprises administering to the patient an effective dose of clobazam or a pharmaceutically acceptable salt thereof.

In some embodiments of the method, the effective dose is less than 10.0 mg / kg / day, or less than 1.0 mg / kg / day, or about 0.8 mg / kg / day, or about 0.5 mg / kg / day, or about 0.2 mg. / kg / day, or about 0.1 mg / kg / day; or about 0.01 mg / kg / day. In some embodiments of the method, the effective dose of fenfluramine is 0.5 mg / kg / day. In some embodiments of the method, the effective dose of fenfluramine is between 0.01 mg / kg / day and 0.8 mg / kg / day.

In some embodiments, the dosage form is an amount selected from the group consisting of 30 mg / day or less, 20 mg / day or less, 10 mg / day or less, and 5 mg / day or less.

In some embodiments of the method, fenfluramine is formulated with a pharmaceutically acceptable carrier.

In some embodiments of the method, fenfluramine is the sole (only) pharmaceutically active drug administered to a patient.

In some aspects of the method, the 5-HT ₄ agonist is at least one of the following:
(A) Inactive at _{5-HT 2B receptor;}
(B) 5-HT _2B receptor neutral agonist; and (c) 5-HT _2B receptor 5-HT _2B receptor inverse agonist.

In some embodiments, the patient exhibits a significantly higher response rate compared to placebo.

In some embodiments, the method further comprises repeating the dosing over a period of days until the patient exhibits a ≥40% reduction in seizure frequency from baseline.

In some embodiments, the patient exhibits at least ≥50% reduction in the frequency of seizures.

In some embodiments, the patient exhibits at least ≧ 75% reduction in the frequency of seizures.

In some embodiments, the patient exhibits at least ≧ 90% reduction in the frequency of seizures.

In some embodiments, the patient has no seizures.

In some embodiments, the patient is alive 2 years after the first dose _{of 5-HT 4 agonist.}

In some embodiments, the method further comprises repeating the administration until the patient is seizure-free for a period of ≧ 1 day.

In some embodiments, the method further comprises repeating administration until the patient is seizure-free for a period of ≥1 week.

In some embodiments, the method further comprises repeating the administration until the patient is free of seizures over a period of ≥1 month.

In some embodiments, the method further comprises repeating administration until the patient is seizure-free for a period of ≥1 year.

In some embodiments, the method further comprises repeating the administration until the patient is permanently seizure-free.

In some aspects of the method, the subject / patient has been diagnosed with epilepsy syndrome selected from the group consisting of Dravet syndrome, Lennox-Gastaut syndrome, Douce syndrome, epileptic spasms, West syndrome, and refractory epilepsy. In some embodiments, the subject / patient has been or may have been treated for epilepsy. In some embodiments, the subject / patient is being treated for epilepsy or epileptic encephalopathy, such as Dravet syndrome and / or Lennox-Gastaut syndrome. In some embodiments, the subject / patient is 18 years or younger. In other embodiments, the subject / patient is an adult (18 years or older).

In some aspects of the disclosure, the symptom of epileptic encephalopathy is seizures (eg, seizures or nonconvulsive seizures). In some aspects of the disclosure, the symptom of epileptic encephalopathy is the unexpected sudden death (SUDEP) of an epileptic patient induced by a seizure. In some aspects of the disclosure, the symptom of epileptic encephalopathy is post-seizure suppression (PID). In some aspects of the disclosure, the symptom of epileptic encephalopathy is seizure-induced respiratory arrest (S-IRA).

In some embodiments of the method, an effective dose of 5-HT4 agonist is administered in a pharmaceutically acceptable carrier.

In some aspects of the method, the 5-HT ₄ agonist is a dosage form adapted to the dosage form selected from the group consisting of oral, intravenous, rectal, subcutaneous, and transdermal dosage forms. It is inside.

In some embodiments of the method, the oral dosage form is selected from the group consisting of liquids, suspensions, tablets, capsules, lozenges, and dissolution strips.

In another aspect, the disclosure provides a kit comprising a therapeutic agent, such as a 5-HT _{4 agonist, and instructions for use in any of the methods disclosed herein.}

As mentioned above and as will be appreciated by those skilled in the art, therapeutic agents are more effective and / or improved compared to fenfluramine or other therapeutic agents and methods currently known in the art. It provides the important advantage of demonstrating safety.

These and other purposes, advantages, and features of the present invention will become apparent to those skilled in the art upon reading the details of the therapeutic agent and its use, which will be described in more detail below.

The present invention will be best understood by reading the following detailed description in conjunction with the accompanying drawings. The following figures are included in the drawings.
It shows a dose-dependent and time-dependent anticonvulsant effect of fenfluramine (FFA) on the susceptibility of DBA / 1 mice to primary auditory seizures (AGSz). It shows a dose-dependent and time-dependent anticonvulsant effect of fenfluramine (FFA) on the susceptibility of DBA / 1 mice to primary auditory seizures (AGSz). It shows a dose-dependent and time-dependent anticonvulsant effect of fenfluramine (FFA) on the susceptibility of DBA / 1 mice to primary auditory seizures (AGSz). It shows a dose-dependent and time-dependent anticonvulsant effect of fenfluramine (FFA) on the susceptibility of DBA / 1 mice to primary auditory seizures (AGSz). The time course of the respiratory arrest (S-IRA) inhibitory effect induced by selective seizures of FFA in DBA / 1 mice is shown (8-hour test protocol). The time course of the respiratory arrest (S-IRA) inhibitory effect induced by selective seizures of FFA in DBA / 1 mice is shown (8-hour test protocol). The time course of the respiratory arrest (S-IRA) inhibitory effect induced by selective seizures of FFA in DBA / 1 mice is shown (8-hour test protocol). The time course of the respiratory arrest (S-IRA) inhibitory effect induced by selective seizures of FFA in DBA / 1 mice is shown (8-hour test protocol). Figure 3 shows 15 mg / kg (n =) with a significant reduction in the mean post-seizure suppression (PID) duration, as defined by the duration of the positive reflex disappearance, compared to the final priming study duration (before drug administration). 10) Shows selective S-IRA inhibition by FFA. Figures 4A and 4B show the reduction of the incidence (frequency) of severe seizures and the prevention of S-IRA by FFA pretreatment. FIG. 5 shows that FFA significantly reduced the incidence (frequency) of tonic seizures, an AGSz phenotype known to lead to S-IRA in the SUDEP DBA / 1 mouse model. FIG. 6 shows the overall incidence (frequency) of selective S-IRA inhibition seen in DBA / 1 mice treated with 5, 10 and 15 mg / kg intraperitoneal FFA using an 8-hour test protocol. _{FIG. 7 shows the effect of 5-HT 4} antagonist (GR125487) on S-IRA inhibition by FFA. FIG. 8 shows that 5-HT ₄ antagonist (GR125487) partially reverses the S-IRA blocking effect of fenfluramine.

Detailed Description Prior to describing the compositions and methods of the invention, it should be understood that the invention is not limited to those, as the particular formulations and methods described can, of course, vary. It is also understood that the terms used herein are merely to describe specific embodiments and are not intended to be limiting, as the scope of the invention is limited only by the appended claims. It should be.

When a range of values is provided, each intervening value between the upper and lower bounds of the range, up to one tenth of the unit of the lower bound, is also specific, unless the context clearly indicates otherwise. It will be understood that it will be disclosed in. Each smaller range between any specified value or intervening value in the specified range and any other specified value or intervening value in the specified range is within the scope of the invention. The upper and lower limits of these smaller ranges may be independently included or excluded, and any or both of the limits may be included, provided that there are any specifically excluded limits within the specified range. Each range included or not included in the smaller range is also included within the scope of the present invention. If the specified range includes one or both of the limits, then a range that excludes one or both of those included limits is also included in the invention.

Unless otherwise stated, all technical and scientific terms used herein have the same meaning as commonly understood by engineers in the field to which the present invention belongs. Any method and material similar or equivalent to that described herein may be used in the practice or testing of the present invention, but preferred methods and materials are described herein. All publications referred to herein are incorporated herein by reference to disclose and describe methods and / or materials in connection with those cited.

Note that the singular forms "a", "an", and "the" as used herein and in the appended claims include multiple referents unless the context clearly indicates otherwise. Must.

Thus, for example, a reference to a "formulation" includes a plurality of such formulations, a reference to a "method" includes a reference to one or more methods and their equivalents known to those of skill in the art, and others. Is the same.

The publications discussed herein provide only those disclosures prior to the filing date of this application. Nothing herein should be construed as an admission that the invention is not entitled to precede such publications because of the prior invention. In addition, the dates of publications offered may differ from the actual publication dates, which will need to be confirmed independently.

The present invention describes the likelihood of unexpected sudden death (SUDEP) of epileptic patients or the severity of seizures in human patients presenting, experiencing, and / or being diagnosed with epilepsy or epileptic encephalopathy. , Based on the surprising finding that agonists of the 5-HT _{4 receptor reduce.}

Therefore, the present disclosure provides a method of using a specific therapeutic agent useful for treating a patient diagnosed with a paroxysmal disease or disorder requiring treatment. The disclosure further provides methods of using specific therapeutic agents useful to prevent, treat or ameliorate symptoms associated with a paroxysmal disease or disorder in a patient in need of treatment.

The methods disclosed herein include administering a therapeutically effective amount of one or more therapeutic agents. Several therapeutic agents can be used in the methods of the invention. In some embodiments, the therapeutic agent is a 5-HT ₄ receptor agonist. In some embodiments, the therapeutic agent is one or more targets, or two or more targets, or three or more targets, or four or more targets, or five or more targets, or it. The above is the activity. In some embodiments, the therapeutic agent is active on _{5-HT 4 receptors.}

The present disclosure provides a method of preventing, treating or ameliorating symptoms associated with a paroxysmal disease or disorder in a patient in need of treatment, wherein the therapeutic agent is a compound that is active in one or more targets. In some aspects, therapeutic agents include compounds that activate 5-HT receptor proteins, such as _{5-HT 4 receptor agonists.}

The disclosure further provides a pharmaceutical composition comprising one or more therapeutic agents disclosed herein for use in the methods of the invention. In some embodiments, the pharmaceutical composition is a formulation adapted to one or more dosage forms, including oral, intravenous, rectal, subcutaneous, and transdermal dosage forms. .. In certain embodiments, the oral dosage form is selected from the group consisting of solutions, suspensions, tablets, capsules, lozenges, and dissolution strips. In one embodiment, the transdermal dosage form is a patch.

The present disclosure further provides a method of preventing, treating or ameliorating one or more symptoms of a disease or disorder in a patient diagnosed with the disease or disorder. In one aspect of this aspect, the patient has been diagnosed with a paroxysmal disorder. In a further embodiment, the paroxysmal disorder is one type of refractory epilepsy, such as Dravet syndrome, Lennox-Gastaut syndrome, Douce syndrome, and West syndrome, as well as other types of refractory epilepsy. In another embodiment, the symptom is seizures, especially status epilepticus. In another aspect, the disclosure provides a method of preventing or reducing the incidence (frequency) of unexpected sudden death (SUDEP) of epilepsy patients in a population of patients. In another embodiment, the patient is obese.

Epilepsy is associated with a 2-3-fold increase in youth mortality compared to the general population. The main cause of this increase in juvenile mortality is the unexpected sudden death (SUDEP) of epileptic patients, which occurs under favorable conditions associated with end-stage seizures but drowning, trauma, toxic effects, or status epilepticus. Excludes related deaths. Most of the witnessed clinical cases of SUDEP reported systemic seizures leading to respiratory and heart failure. The lifetime risk of SUDEP among epilepsy patients is estimated to be up to 8%, and young epilepsy patients are 24 or 28 times more likely to have unexpected sudden death than the general population. SUDEP is second only to stroke in neurological disorders in terms of life loss. The main pathophysiological mechanisms associated with SUDEP include respiratory failure, arrhythmias and brain dysfunction. There is an urgent need to find a drug that can prevent SUDEP as there is currently no effective treatment. One measure of seizure severity is to measure frequency and / or duration.

The DBA / 1 mouse model of SUDEP is chronically and abnormally sensitive to fatal seizures (seizure-induced death) induced by electric shock, heat, convulsants, and acoustic stimuli. High-intensity acoustic stimuli induce a seizure-induced seizure (AGSz) consisting of tonic-clonic seizures followed by seizure-induced respiratory arrest (S-IRA) (leading to death in the period immediately following the seizure). .. Timely mechanical support of breathing can consistently reverse S-IRA in this SUDEP model. (Faingold CL, Randall M, Tupal S. 2010. DBA / 1 mice exhibit chronic susceptibility to audiogenic seizures followed by sudden death associated with respiratory arrest. Epilepsy Behav. 17: 436-40).

The study revealed a deficiency in serotonin production and receptor expression in DBA / 1 mice. With all drugs that enhance serotoninergic neurotransmission, including selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine, fluvoxamine and sertraline, or drugs that inhibit serotonin-norepinephrine reuptake such as venlafaxine and atomoxetine Many, but not many, have been reported to dose-dependently prevent seizure-induced respiratory failure and death in DBA mice. In contrast, serotonin antagonists increase the susceptibility of DBA mice to S-IRA. These findings and additional studies on other SUDEP models elicited the serotonergic hypothesis of SUDEP.

SUDEP's serotonin hypothesis is based on the finding that treatments that alter serotonergic function significantly alter susceptibility to seizure-induced sudden death in several epilepsy models, including DBA / 1 mice. Recently, human SUDEP has been found to have serotonergic abnormalities.

The entire content of US Patent Application Publication No. 2018/0092864 (US Patent Application No. 15/717159) is incorporated herein by reference in its entirety, but as disclosed herein, the (5-HT) receptor sub. Types (eg, 5-HT _1A , 5-HT _1D , 5-HT _1E , 5-HT _2A , 5-HT _2C , 5-HT ₄ , 5-HT _5A and 5-HT ₇ ) and other receptors, For example, adrenaline receptor (eg β-1 or β-2 adrenaline receptor), muscarinic acetylcholine receptor protein (eg M1, M2, M3, M4 or M5 muscarinic acetylcholine receptor), chaperon protein (eg M1) Sigma 1 or Sigma 2 receptor), or potential-dependent sodium channel subunit protein or its subsystems (eg, Nav1.1, Nav1.2, Nav1.3, Nav1.4, Nav1.5, Nav1.6, or Nav1.7) and / or fenfluramine and fenflu at various receptors, including neurotransmitter transport proteins (eg, serotonin transporter (SET), dopamine transporter (DAT), norepinephrine transporter (NET)) Methods are provided for determining the binding properties, activity (eg, agonist or antagonist) selectivity, specificity and pharmaceutical effect of a lamin analog. Testing in animal models has led to the unexpected finding that certain of these candidates surprisingly reduced epilepsy-like activity in in vivo animal models.

Recently, the contribution of several serotonin receptor subtypes in mediating the action of fefluramine in the prevention of seizure-induced sudden death was evaluated in the DBA / 1 mouse model of SUDEP. In these studies, fenfluramine, known to enhance the release of serotonin (5-hydroxytryptamine, 5-HT) in the brain, is induced by auditory primary seizures (AGSz) and seizures in DBA / 1 mice. It proved to be effective in blocking respiratory arrest (S-IRA). However, prior to this disclosure, it was unclear whether the effects of fenfluramine were mediated by specific 5-HT receptors. Therefore, as disclosed in the present invention, the effects of fenfluramine were investigated using several 5-HT receptor-specific antagonists, and the 5-HT antagonists were fenfluramine-mediated anticonvulsant activity ( We determined whether and / or S-IRA inhibition, or any other effect) could be reversed and identified a subset of 5-HT receptors to which fenfluramine binds and acts as agonists.

For these experiments, using DBA / 1 mice (N = 287) (after undergoing established priming procedures to ensure consistent susceptibility to S-IRA after AGSz), various 5- The effect of fenfluramine on HT receptors was evaluated. Seizures were induced using an electric bell and revived using a rodent ventilator (Faingold et al., 2010). Mice were administered FFA (15 mg / kg, i.p.) at least 24 hours after priming and tested for AGSz and S-IRA susceptibility 16 hours later. Thirty minutes prior to AGSz induction, selective 5-HT receptor antagonists or vehicles were administered to assess whether specific receptors contributed to FFA's ability to block S-IRA. Seizure behavior was recorded on videotape, quantified, and statistically compared to vehicle-treated negative controls and FFA-treated positive controls (chi-square test; significance set to p <0.05).

Specifically, the antagonists tested were: 5-HT _1A antagonist, WAY100635 (0.1-15 mg / kg); 5-HT ₂ antagonist, ritanserin (10-20 mg / kg); 5-HT ₃ antagonist, ondansetron ( 1-3 mg / kg); 5-HT ₄ antagonist, GR125487 (20-60 mg / kg); 5-HT _5A antagonist, SB669551 (10-20 mg / kg); and 5-HT ₇ antagonist, SB269970 (30-40 mg / kg) kg). Studies are also underway to investigate the effects of 5-HT ₆ and 5-HT _{1a / 1b antagonists.}

In particular, a reversal of FFA-inducible reduction in S-IRA incidence (frequency) was observed after treatment with 5-HT4 antagonists (GR125487, 30 mg / kg). This dose was effective in inducing this significant (p <0.05) inhibition of FFA-induced reduction in S-IRAs. Antagonists of 5-HT ₂ , 5-HT ₄ and 5-HT ₇ receptors were found to reverse the anticonvulsant effect of FFA on the severity of AGSz in mice, but not the S-IRA blocking effect of FFA. On the other hand, 5-HT _1a and 5-HT ₃ receptor antagonists were ineffective at any dose tested.

Specifically, a significant (p <0.05) partial reversal of FFA-induced S-IRA inhibition was observed after 30 minutes of treatment with a 5-HT _{4 antagonist (GR125487, 30 mg / kg).} Therefore, GR125487 was effective in inducing significant inhibition of S-IRA inhibition of fenfluramine (see Figures 7 and 8). Interestingly, antagonists of 5-HT ₂ , 5-HT ₄ and 5-HT ₇ receptors were found to reverse the anticonvulsant effect of FFA on the severity of AGSz, but not the S-IRA blocking effect. bottom.

Antagonists of 5-HT ₂ (20 mg / kg, ritanserin), 5-HT ₄ (30 and 60 mg / kg, GR125487) and 5-HT ₇ (30 mg / kg and 40 mg / kg, SB269970) receptors are severely ill with AGSz. The anti-convulsant effect of FFA on degree could be reversed. A 5-HT _5a antagonist, SB669551, blocked the anticonvulsant effect of FFA at 20 mg / kg. In contrast, 5-HT _1A (WAY100635, 0.1-15 mg / kg) and 5-HT ₃ (ondansetron, 1-3 mg / kg) receptor antagonists were ineffective at any dose tested.

These findings suggest that the anticonvulsant effect of FFA on AGSz-induced S-IRA in DBA / 1 mice is relatively selectively mediated as a result of _{5-HT 4 receptor activation.} doing. _{It may be related that the expression level of 5-HT 4} receptor in the brain of DBA / 1 mice is not significantly different from that of normal mice (Faingold et al., 2011). This result is surprising in light of previous studies on receptors that mediate the ability of selective serotonin reuptake inhibitors to reduce seizure severity and block S-IRA, selective 5-HT ₃ It can only be reversed by antagonists (Faingold et al., 2016). Therefore, agonists that activate certain 5-HT receptors (eg, 5-HT ₄ receptor agonists) are for future testing in animal models of SUDEP, and as a possible preventative measure for human SUDEP. Is the subject of interest.

In general, _{antagonists of 5-HR 1A} , 5-HT ₃ , and receptors do not reverse the effects of fenfluramine, and the effects of fenfluramine on S-IRA and / or AGSz are with these receptors. It suggests that it is not mediated by interaction. In contrast, 5-HT ₂ , 5-HT _5A , and 5-HT ₇ antagonists (ritanserin, 20 mg / kg; SB669551, 20 mg / kg; and SB269970, 30 mg / kg and 40 mg / kg) have anticonvulsant effects on FFA. It was found to block fenfluramine, suggesting that the anticonvulsant effect of fenfluramine may be mediated by interaction with these receptors. In particular, compound GR125487 was found to partially reverse the anticonvulsant and S-IRA inhibitory effects of fenfluramine, allowing fenfluramine to act specifically as an agonist at the _{5-HT 4 receptor.} It was concluded that it turned out.

Therefore, the anticonvulsant effect of FFA on AGSz-induced S-IRA in DBA / 1 mice is mediated, at least in part, by activation of _{5-HT 4 receptors. Expression levels of 5-HT 4} receptors in the brains of DBA / 1 mice are not significantly different from those of normal mice (Faingold et al., 2011). These results are surprising in light of previous studies on receptors that mediate the ability of selective serotonin reuptake inhibitors to reduce seizure severity and block S-IRA, and selective 5- It can only be reversed by HT ₃ antagonists (Faingold et al., 2016).

Agonists that activate specific 5-HT receptors are of interest for future studies in animal models of SUDEP and as a possible preventative measure for human SUDEP.

The present disclosure provides a method of reducing the incidence of human patients seizure (frequency) or severity, stage administering a therapeutically effective dose of 5-HT ₄ agonist to the patient, and the 5-HT ₄ agonists _{The 5-HT 4} agonist is fenfluramine, comprising stimulating the patient's 5-HT ₄ receptor thereby reducing the incidence (frequency) or severity of the patient's seizures, said. Aim for the method.

The present disclosure is a method of inhibiting respiratory arrest (S-IRA) induced by a human patient's attack, in which _{a therapeutically effective dose of a 5-HT 4} agonist is administered to the patient, and 5-HT _{4 The 5-HT 4} agonist comprises the step of stimulating the patient's 5-HT 4 receptor thereby inhibiting respiratory arrest (S-IRA) induced by the patient's seizure, where the 5-HT ₄ agonist is fenfluramine. The purpose is the above method.

The present disclosure provides a method of reducing the length of the post-human patient seizure (PID) the average period, step administering a therapeutically effective dose of 5-HT ₄ agonist to the patient, and 5-HT ₄ agonists Including the step of stimulating the patient's 5-HT ₄ receptor, thereby reducing the average length of the post-attack post-attack suppression (PID) period of the patient, where the 5-HT ₄ agonist is fenflu. The object is the method described above, which is a lamin.

The present disclosure is a method of reducing the probability of an unexpected sudden death (SUDEP) of an epilepsy patient induced by an attack in a human patient, wherein _{a therapeutically effective dose of a 5-HT 4} agonist is administered to the patient. The 5-HT ₄ agonist comprises a step of stimulating the patient's 5-HT ₄ receptor, thereby reducing the accuracy of SUDEP of the patient, wherein the 5-HT ₄ agonist is fenfluramine. , The above method is intended.

Therefore, one method proposed to treat epilepsy and / or epileptic encephalopathy is to stimulate one or more 5-HT receptors in the patient's brain, and fenfluramine is effective. The dose may be administered to the patient. In some aspects of the disclosure, one or more 5-HT receptors are among other 5-HT ₁ , 5-HT _1A , 5-HT _1B , 5-HT _1C , 5-HT _1D , 5-HT. _1E , 5-HT _1F , 5-HT ₂ , 5-HT _2A , 5-HT _2B , 5-HT _2C , 5-HT ₃ , 5-HT ₄ , 5-HT ₅ , 5-HT _5A , 5-HT Selected from _5B 5-HT ₆ and 5-HT _7. In some aspects of the disclosure, the 5-HT receptor is 5-HT ₄ . In certain aspects of the disclosure, the patient has been diagnosed with epilepsy.

Without being bound by theory, fenfluramine (FFA) enhances the carrier-mediated synaptic release of serotonin (5-HT) in the brain by disrupting its vesicle storage and inhibits its reuptake. By enhancing serotoninergic neurotransmission. Its active metabolite, norfenfluramine (N-FFA), contributes to the prolongation of this effect. In recent clinical trials, FFA treatment is an addition (assistant) to improve seizure control in patients with intractable seizures characteristic of Dravet syndrome who are difficult to treat and have a tragicly high risk of SUDEP. It turned out to be effective as an agent. Administration of the drug fenfluramine significantly reduced the frequency and / or severity of seizure activity and, in some cases, completely eliminated it.

Studies in a zebrafish model of Dravet syndrome have also shown that FFA is effective in blocking electrograph activity as well as seizure-like behavioral activity. In light of these findings, the present disclosure investigated whether fenfluramine could reduce S-IRA susceptibility and seizure frequency and / or severity in DBA / 1 mice.

This disclosure is the first study investigating the efficacy of FFA in a mammalian model of SUDEP. Therefore, the present disclosure aims to elucidate the effect of FFA on seizures; in addition, the effect of FFA on seizure-induced respiratory arrest (S-IRA) in DBA / 1 mice was investigated.

As disclosed herein, fenfluramine acts as an anticonvulsant in certain serotonin receptor subtypes in the DBA / 1 mouse model and is seizure-induced respiratory arrest (S-IRA) and seizure-induced. It has been found to prevent unexpected sudden death (SUDEP) in patients with epilepsy. Prior to this disclosure, the mechanism of FFA efficacy in the treatment of seizures was unknown and it was unclear whether the effects of FFA were mediated by any particular 5-HT receptor. The study revealed that FFA has specific effects on specific 5-HT receptor subtypes, and that specific 5-HT antagonists can reverse the anticonvulsant and S-IRA blocking effects of FFA. Judged. In some aspects of the disclosure, the 5-HT receptor is 5-HT ₄ .

Fenfluramine (FFA), which acts to enhance the release of serotonin (5-hydroxytryptamine, 5-HT) in the brain, is the primary auditory seizure (AGSz) and seizure-induced respiration in these DBA / 1 mice. It turned out to be effective in stopping the outage.

Specific Aspects of the Invention Provided are a diagnosis of refractory epilepsy or epileptic encephalopathy, including, but not limited to, Dravet syndrome, Lennox-Gastaut syndrome, Dokus syndrome, punctate and West syndrome, and other refractory epilepsy. A therapeutic agent useful for preventing, treating, or ameliorating a disease or disorder-related symptom of a patient diagnosed with the disease or disorder, including, but not limited to, the affected patients. Also provided are seizures and seizure-induced respiratory arrest (S-IRA) that lead to unexpected sudden death (SUDEP) of epilepsy patients associated with the disease or disorder of a patient diagnosed with the disease or disorder. Pharmaceutical compositions and formulations comprising methods of preventing, treating, or ameliorating such symptoms, as well as agents useful in carrying out the methods of the invention.

Therapeutic Agents We anticipate patients with intractable seizures, seizure-induced respiratory arrest (S-IRA) and / or epilepsy, including, but not limited to, diseases or disorders associated with epilepsy or epileptic encephalopathy. We have made a surprising finding that certain therapeutic agents (eg, fenfluramine (FFA)) are useful in treating diseases or disorders that indicate epileptic death (SUDEP). Therefore, in accordance with one aspect of the disclosure, what is provided herein is useful in treating a patient diagnosed with a disease or disorder and / or prevents or prevents the symptoms of the disease or disorder exhibited by the patient. It is a therapeutic agent that is useful for improving.

Dose / Frequency of Administration: The dosage form can be formulated for once-daily administration or multiple-daily administration (eg, 2, 3 or 4 times daily). Alternatively, for convenience, the dosage form can be formulated for less frequent administration (eg, monthly, biweekly, weekly, every 4 days, every 3 days, or every 2 days) to promote sustained release. Formulations are known in the art.

The phrase "half Chronic administration" as used herein, therapeutic agents, such as fenfluramine or 5-HT ₄ receptor agonist, a few days, a week, several weeks, one month, several months, one year, Or refers to administration for a period of several years.

Binding of Single or Multiple Targets In some embodiments, the therapeutic agents provided by the present disclosure are one or more targets, eg, two or more targets, three or more targets, four or more targets, 5 It can bind to one or more targets, or more.

Receptor protein target In some embodiments, the therapeutic agent binds to a _{5-HT 4 receptor.}

In some embodiments, the therapeutic agent comprises a sigma-1 receptor and one or more 5-HT receptors, such as 5-HT _1A receptor, 5-HT _1D receptor, 5-HT _1E receptor, It binds to 5-HT _2A receptor, 5-HT _2C receptor, 5-HT ₄ receptor, 5-HT _5A receptor, and / or 5-HT _{7 receptor.} In some embodiments, the therapeutic agent binds to the _{sigma-1 and 5-HT 4 receptors.}

Functional activity In accordance with the present disclosure, the term "active" or "active" is used herein to mean having an effect on cell, nucleus, or tissue function, and is used as agonistic activity, reverse agonistic activity, antagonist. It is intended to include activity, synergism, allosteric agonism, allosteric regulation including positive, negative and neutral allosteric regulation, allosteric regulation including positive, negative and neutral allosteric regulation, and ligand capture.

Receptor activity In some embodiments, the therapeutic agent is 5-HT _1A receptor, 5-HT _1D receptor, 5-HT _1E receptor, 5-HT _2A receptor, 5-HT _2C receptor, 5- It is active on one or more 5-HT receptor proteins selected from the group consisting of HT ₄ receptor, 5-HT _5A receptor, and / or 5-HT _{7 receptor.} In some embodiments, the therapeutic agent is active on _{5-HT 4 receptors.}

Therapeutic agents that are active on multiple targets This disclosure discloses treatments that are active on one or more targets, such as two or more targets, three or more targets, four or more targets, five or more targets, or more. Further provide the agent.

For example, in one embodiment, the present disclosure provides a therapeutic agent that is active on two or more 5-HT receptors. In this regard, the present disclosure describes the unexpected sudden death (SUDEP) of epileptic patients in patients with seizure disorders or disorders, epilepsy and / or epileptic encephalopathy, in which _{fenfluramine acts on the 5-HT 4 receptor.} It is aimed at the surprising finding that it is useful in preventing, treating or ameliorating symptoms such as respiratory arrest (S-IRA) induced by linked seizures.

Therapeutic agents that are inactive at the 5-HT _2B receptor In a preferred embodiment, the therapeutic agents disclosed herein cause adverse effects such as valvular disease, pulmonary hypertension or other adverse effects at _{the 5-HT 2B receptor.} Not active enough to. In another exemplary embodiment, the agent, 5-HT _2B does not bind to receptors or 5-HT _2B antagonists (i.e., agents that block the activity of an agonist) reverse antagonists of a or 5-HT _2B,, ( That is, it is an agonist (an agonist that reduces the basal activity of the receptor) or _{a neutral agonist of the 5-HT 2B} receptor (ie, a compound that blocks the binding of the agonist).

Diseases and Disorders The therapeutic agents provided by the present disclosure are useful in treating some diseases and disorders and / or in reducing or ameliorating their symptoms. For example, the therapeutic agents disclosed herein are useful in treating types of epilepsy such as Dravet syndrome, Lennox-Gastaut syndrome, Douce syndrome, head cramps, West syndrome, and other intractable epilepsy syndromes. , Useful for preventing, alleviating or ameliorating the symptoms of patients diagnosed with those conditions. The therapeutic agents provided herein are also useful in preventing cognitive impairment that affects learning, memory, cognition, and / or problem solving, including, but not limited to, amnesia, dementia, and delirium.

Usage The therapeutic agents described above can be used in a variety of ways. As mentioned above, aspects of this method include, for example, to a patient diagnosed with a disease or condition of interest, to treat a patient in need of treatment, or a disease or disorder of a patient diagnosed with that disease or disorder. Including the step of administering a therapeutically effective amount of a therapeutic agent described herein in order to prevent, alleviate or ameliorate the symptoms of the disorder. Examples include seizures, especially status epilepticus, seizure-induced respiratory arrest (S-IRA), and unexpected sudden death of epileptic patients (SUDEP). A "therapeutically effective amount" is the treatment or treatment of epilepsy and related symptoms and comorbidities that include, but are not limited to, the desired biological effect (eg, seizure-induced sudden respiratory arrest (S-IRA)). It means the concentration of the compound sufficient to induce (prevention). Diseases and conditions of interest include intractable epilepsy, including, but not limited to, Dravet syndrome, especially Dravet syndrome, Lennox-Gastaut syndrome, Douce syndrome, epileptic spasms, West syndrome, and other refractory epilepsy. Includes, but is not limited to, other neurorelated disorders, obesity, and obesity-related disorders. Also of interest is the prevention or amelioration of symptoms and comorbidities associated with these diseases.

In some embodiments, the method of the invention comprises administering to a subject a compound for treating a nerve-related disease. Neurological disorders of interest include, but are not limited to, severe myoclonic epilepsy in infancy (Dravet syndrome), Lennox-Gastaut syndrome, Douce syndrome, epileptic spasms, West syndrome, and other refractory epilepsy. , Especially including severe or refractory epilepsy, but not limited to. In some embodiments, the methods of the invention enclose symptoms including, but not limited to, S-IRA, SUDEP, and comorbidities.

Genetic testing Some therapeutic agents provided by the present disclosure in some cases, especially when the use of a particular drug is contraindicated because it is ineffective or has unwanted or serious side effects. It may be desirable to test for genetic mutations in patients prior to administration of. Therefore, it may be desirable to examine the patient before treatment. For patients with Dravet syndrome, SCN1A (eg, in the voltage or pore regions S4 to S6), SCN1B (in the region encoding the sodium channel β1 subunit, etc.), SCN2A, SCN3A, SCN9A, GABRG2 (γ2 subunit) Can be tested for mutations (such as partial or complete deletion mutations, cleavage mutations and / or missense mutations) in GABRD (such as in the region encoding the σ subunit), I or PCDH19. The gene is associated with Dravet syndrome.

Similarly, several reports in the literature have demonstrated strong and probable multifactorial genetic components for Doose syndrome (see, eg, Kelly et al., Developmental Medicine & Child Neurology 2010, 52: 988-993). ), Sodium channel neuron type 1 α subunit (SCN1A) mutation, sodium channel subunit β-1 (SCN1B) and gamma aminobutyric acid receptor subunit γ-2 (GABRG2) mutation; including point mutation in Exxon 20 of SCN1A Several mutations appear in many patients with Doose syndrome.

Other genetic tests can be performed and may be required as a condition of treatment.

Dosing The different therapeutic agents disclosed herein can be administered to patients in different amounts depending on the age, size, gender, condition of different patients and the use of different therapeutic agents.

For example, the dosing can be a daily dosing based on body weight. However, for convenience, the dosage can be preset. In general, the lowest dose effective for a particular patient should be used. Patients can be dosed daily using a single dosing unit that may consist of an amount of therapeutic agent suitable for a particular drug. The dosing unit can be selected based on the route of delivery, for example, the dosing unit is by oral delivery, transdermal delivery, rectal delivery, vaginal delivery, oral delivery, intranasal and / or inhalation delivery, lung delivery or injection. Can be delivery specific.

Preparations The dosage of the therapeutic agent administered by the method of the present invention may be an oral disintegrating tablet, a capsule, a lozenge, an oral solution or syrup, an oral emulsion, an oral gel, an oral film, a buccal solution, for example, a powder for suspension. Oral dosage forms such as tablets; injectable dosage forms; transdermal dosage forms such as transdermal patches, ointments, creams; inhalation dosage forms; and / or nasally, rectal, vaginal dosage forms, including, but not limited to. , Can be formulated into any pharmaceutically acceptable dosage form. Such dosage forms can be formulated for once-daily administration or for multiple daily administrations (eg, 2, 3 or 4 times daily).

The particular formulation of the invention is in liquid dosage form. The liquid can be a solution or suspension and can be an oral solution or syrup contained in a pipette-equipped bottle graduated with a milligram amount to obtain a given amount of solution. Liquids allow for the preparation of pediatric liquids that can be administered in increments suitable for a particular therapeutic agent.

Administration of the compounds of the invention can be systemic or topical. In certain embodiments, administration to a mammal results in systemic release (eg, into the bloodstream) of a compound of the invention. Administration methods may include enteral routes such as oral, oral, sublingual, and rectal; topical administration such as transdermal and intradermal; and parenteral administration. Suitable parenteral routes include subcutaneous needle or catheter injections, such as intravenous, intramuscular, subcutaneous, intradermal, intraperitoneal, intraarterial, intraventricular, intrathecal, and anterior atrioventricular injections. Non-injection routes such as intravaginal or intranasal administration are included. In certain embodiments, the compounds and compositions of the invention are orally administered. In certain embodiments, it may be desirable to administer the compound topically to the area in need of treatment. In some embodiments, the method of administration of the compounds of the invention is parenteral administration. This can be achieved, for example, by topical injection during surgery, for example by topical application in conjunction with a post-surgical wound dressing, by injection, by a catheter, by a suppository, or by an implant, the implant being A porous, non-porous, or gelatinous material containing a membrane, such as a sialastic membrane, or fibers.

In some embodiments, the method of the invention comprises administering to the subject an appetite-suppressing amount of a compound of the invention for treating obesity. Any convenient method for treating obesity can be adapted for use with the therapeutic agents of the present invention. Any pharmaceutical composition described herein may be useful in treating obesity in a subject. The combination therapy is the administration of a single pharmaceutical dosage product containing the compound of the present invention and one or more additional agents; and the individual separate of the compound of the present invention and one or more additional agents. Pharmaceutical administration Includes administration in the form of a preparation. For example, the compounds of the present invention and additional agents with appetite-suppressing activity (eg, phentermine or topiramate) can be administered together to the patient in the form of a single dosage composition, such as a combination formulation, or each. The drug can also be administered in the form of separate administration formulations. When the separate dosage formulations are used, the compounds of the present invention and one or more additional agents can be administered simultaneously or separately, eg, sequentially, at staggered times. In some embodiments, the method further comprises co-administering the antiepileptic agent with the therapeutic agent of the invention to the subject. Antiepileptic agents of interest useful in co-administration methods include acetazolamide, carbamazepine, (tegretol), onfi (clovasam), chronazepam (chronopin), lamotrigine, nitrazepam, pyracetam, phenytoin, retigabin, stiripentol, topiramate. , And carbamazepine, Epitol, Equetro, Gabitril (thiagabin), kepra (levetylacetam), lamictal (lamotridin), lyrica (pregabalin), glaris (Gralise), horizont, neurotin, gavalon ( Gabapentin, Dirantin, Prompt, Di-Phen, Epanutin, Phenytek, Phenytek, Topamax, Qudexy XR, Trokendi XR, Topiragen ) (Topiramate), Trireptal, Oxtellar (Oxtellar), Depacon, Depaken, Depakote, Stavzor (Valproate, Valproic acid), Zonegran (Zonegran), Ficompa (peran panel), Aptiom (eslicarbamazepine acetate), binpat (lacosamide), sabryl (bigabatrin), banzel, inovelon (rufinamide), cerebyx (phosphenytoin) ), Zarontin (Etoscusmid), Solfoton, Luminal (Phenytoin), Barium, Diastat (Diazepam), Achiban (Lorazepam), Lonopin (Lonopin), Chronopin (Kronazepam), Frisium, Pochiga (Potiga) (Ezogabin), Felbatol (Felbamate), Mysolin (Primidone), but not limited to them.

In some embodiments, the method of the invention is an in vitro method comprising contacting a sample with a compound of the invention. There are many protocols that can be used with these methods: cellotonin release test from nerve cells, cell-free test, binding test (eg, 5-HT _2B receptor binding test); cell test to measure cell phenotype, eg gene expression. Tests; and include specific animal models for conditions of interest (eg, Dravet syndrome, Lenox-Gasteau syndrome, Douce syndrome, West syndrome, and other refractory epilepsy) or symptoms or comorbidities associated with such conditions. Tests are included, but not limited to them.

Pharmaceutical products Similarly, pharmaceutical products are provided. A pharmaceutical formulation is a composition that comprises a compound that is present in a pharmaceutically acceptable vehicle (either alone or in the presence of one or more additional active agents). The term "pharmaceutically acceptable" is approved by federal or state government regulators for use in mammals such as humans, or listed in the United States Pharmacopeia or other generally accepted pharmacopoeia. It means that it has been done. The term "vehicle" means a diluent, adjunct, excipient, or carrier that formulates a compound of the invention with it for administration to a mammal.

The choice of excipient is determined in part by the particular compound as well as by the particular method used to administer the composition. Therefore, there are various formulations suitable for the pharmaceutical composition of the present invention.

The dosage form of the therapeutic agent used in the method of the present invention combines the therapeutic agent with one or more pharmaceutically acceptable diluents, carriers, adjuvants, etc. in a manner known to those skilled in the art of pharmaceutical formulations. Can be prepared by

For example, therapeutic agents are mixed with conventional pharmaceutically acceptable carriers and excipients (ie, vehicles) to include aqueous solutions, tablets, capsules, elixirs, suspensions, syrups, wafers, etc. Can be used in form. Such pharmaceutical compositions, in certain embodiments, comprise from about 0.1% to about 90% by weight of active compound, more generally from about 1% to about 30% by weight of active compound. Pharmaceutical compositions include corn starch, gelatin, lactose, dextrose, sucrose, microcrystalline cellulose, kaolin, mannitol, dicalcium phosphate, sodium chloride, alginic acid, vegetable oils or other similar oils, synthetic fatty acid glycerides, higher fatty acids or Includes, but not limited to, propylene glycol esters, corn starch, potato starch, acacia, tragacant, gelatin, glycerin, sorbitol, ethanol, polyethylene glycol, colloidal silicon dioxide, croscarmellose sodium, talc, magnesium stearate and stearic acid. Common solubilizers, tonicity agents, suspending agents, emulsifiers, stabilizers, preservatives, colorants, diluents, buffers, surfactants, wetting agents, flavoring agents and disintegrants, etc. Carriers and excipients may be included. Disintegrants commonly used in the formulations of the present invention include croscarmellose, microcrystalline cellulose, cornstarch, sodium starch glycolate and alginic acid. The compound is made into an aqueous or non-aqueous solvent such as a vegetable oil or other similar oil, a synthetic fatty acid glyceride, a higher fatty acid or an ester of propylene glycol; if desired, a solubilizer, isotonic agent, suspending agent. It can be formulated into an injectable preparation by dissolving, suspending or emulsifying with conventional additives such as emulsifiers, stabilizers and preservatives.

In some embodiments, the formulations suitable for oral administration include (a) liquids, such as an effective amount of the compound dissolved in a diluent such as water or saline; (b) each given amount of activity. Capsules, sachets or tablets containing the ingredients as solids or granules; (c) suspensions in suitable liquids; and (d) suitable emulsions may be included. The dosage forms of the tablets are lactose, mannitol, corn starch, potato starch, microcrystalline cellulose, acacia, gelatin, colloidal silicon dioxide, croscarmellose sodium, talc, magnesium stearate, stearate, and other excipients, coloring. It may contain one or more agents, diluents, buffers, wetting agents, preservatives, flavoring agents, and pharmacologically compatible excipients. The dosage form of Rosenji contains, in addition to the active ingredient, excipients such as those described herein, flavors, usually sucrose and the active ingredient in acacia or tragacanth, as well as gelatin and glycerin, or sucrose. And sucrose containing the active ingredient in an inert base such as acacia, emulsion, gel, etc. may be included.

In some cases, the compound is formulated for oral administration. In some cases, for oral pharmaceutical formulations, suitable excipients include mannitol, lactose, glucose, sucrose, starch, cellulose, gelatin, magnesium stearate, sodium saccharin, and / or magnesium carbonate. , Pharmaceutical grade carriers are included. For use in oral liquid formulations, the composition is a solid or liquid suitable for hydration in an aqueous carrier such as, for example, aqueous saline, aqueous dextrose, glycerol, or ethanol, preferably water or normal saline. It can be prepared as a liquid, suspension, emulsion, or syrup, supplied in any of the molds. If desired, the composition can also include small amounts of non-toxic auxiliary substances, such as wetting agents, emulsifying agents, or buffering agents.

The particular formulation of the invention is in liquid dosage form. The liquid can be a solution or suspension and can be an oral solution or syrup contained in a pipette-equipped bottle graduated with a milligram amount to obtain a given amount of solution. Depending on the solution, somewhere between 0.5 mL and 15 mL, and any amount in between, can be administered in increments of 0.5 milligrams, and thus can be administered in 0.5, 1.0, 1.5, 2.0 mL, etc., for children. The liquid agent can be adjusted.

Liquid compositions generally include suitable liquid carriers such as ethanol, glycerin, sorbitol, non-aqueous solvents such as polyethylene glycol, oils or compounds in water or pharmaceutically acceptable salts, and suspending agents, preservatives. Consists of suspensions or solutions with surfactants, wetting agents, flavoring or coloring agents. Alternatively, the liquid formulation can be prepared from a powder for reconstruction.

The following examples are intended to fully disclose and describe to those skilled in the art how to make and use the invention and are intended to limit the scope of what the inventors consider to be the invention. Nor is it intended to indicate that the following experiments are all or the only experiments performed. Efforts have been made to ensure accuracy with respect to the numbers used (eg, quantity, temperature, etc.), but some experimental errors and deviations should be considered. Unless otherwise stated, parts are parts by weight, molecular weight is weight average molecular weight, temperature is degrees Celsius, and pressure is at atmospheric pressure or near atmospheric pressure.

Several selective serotonin (5-HT) reuptake inhibitors have been found to prevent seizure-induced respiratory arrest (S-IRA) in DBA mice. However, not all drugs that enhance 5-HT receptor activation effectively block S-IRA in DBA mice. Therefore, we investigated fenfluramine (FFA) to determine whether its enhanced 5-HT release alters the susceptibility of DBA / 1 mice to primary auditory seizures and S-IRA.

Example 1
Effects of fenfluramine in animal models of SUDEP Materials and Methods Animals These studies included male DBA / 1 mice of the same age (<80 days) obtained from ENVIGO. Males were used in this study because there were no significant gender differences in AGSz incidence (frequency), severity, and S-IRA susceptibility in DBA / 1 mice. Mice were primed as described in previous studies (Faingold et al., (2010). Epilepsy Behav. 17: 436-40; Faingold, et al. (2011) Brain Res. 1418: 104-10; Faingold, et al., (2011) Epilepsy Behav. 22: 186-90). Simply put, mice were freely fed and maintained in a temperature and humidity controlled laboratory veterinary medical facility under a 12 hour light-dark cycle. Starting 23-25 days after birth, mice were primed and tested for consistent susceptibility to AGSz and S-IRA by strong speech stimuli, as previously described. Mice that showed consistent susceptibility to S-IRA in three consecutive studies were included in the following studies.

Seizure induction and resuscitation
AGSz was applied to each DBA / 1 mouse (N = 287) from a strong (110dB SPL; re: 0.0002dyne) from an electric bell (Heath Zenith Model # 172C-A) installed inside a plastic cylinder (diameter 43cm). / cm ² ) Induced by presenting a broadband speech stimulus. Epilepsy Behav. Epilepsy Behav. DBA / 1 mice exhibit chronic susceptibility to audiogenic seizures followed by sudden death associated with respiratory arrest. 17: 436-40).

Stimulation was presented until the mice showed tonic seizures or for a maximum duration of 60 seconds. Typical seizure symptoms in DBA / 1 mice begin with the wild-running phase, followed by clonic tonic seizures, followed by strong immediate limb extension that immediately leads to S-IRA during post-seizure behavioral depression (PID). .. Initiation of S-IRA was visually determined by loss of forward reflex, relaxation of the pinna, and then respiratory failure after loss of systemic muscle tone. These behaviors are a reliable indicator of the imminent sudden death of DBA mice. Resuscitation was initiated within 10 seconds after auricular relaxation and generalized muscle tone loss, which was effective in reversing S-IRA and reviving> 90% of mice. A polyethylene tube (outer diameter 4.4 mm) connected to the outflow of the rodent respirator (Harvard SFP 680), with the mouse in the supine position and pumping 1 cc of indoor air at 200 beats / minute, was placed in the nostril. Placed on top, this caused an observable displacement of the chest. Respiratory support was provided until the spontaneous respiratory rhythm returned, which took about 19 seconds. Mice were monitored until they regained their forward reflex and then returned to their cages. Video recordings of seizure behavior and recovery, including the duration of PID, indicated by the time from loss of muscle tone to return of the forward reflex, were performed for offline assessment and analysis.

Behavioral Tests The experiments disclosed herein use FFA (10-40 mg / mg /) for AGSz-induced behavior in DBA / 1 mice compared to vehicle-treated control mice using different seizure test protocols. The dose-response relationship of kg and ip) was investigated. This initial protocol included induction of AGSz 30 minutes, 12 and 24 hours after drug administration, and then at 24-hour intervals until regaining susceptibility to S-IRA. These studies aimed to determine whether FFA could reduce the incidence (frequency) and severity of AGSz and susceptibility to S-IRA. Based on these results, a dose range of 5-20 mg / kg was selected, using 8-hour intervals for the first 24 hours and then over a 24-hour period to evaluate the time course of effect in detail. The second seizure test protocol was used to determine the time course of FFA effects in another group of DBA / 1 mice. An ordinal scoring system by De Saro et al. Was used to determine the effect of FFA on the severity of AGSz in DBA / 1 mice: no seizures = 0; wild running = 1; clonic seizures = 2; tonic seizures = 3; Death / S-IRA = 4. 50% effective amount of FFA to prevent AGSz the ip injection 30 minutes after the DBA / 1 mice (ED _50), best fit quadratic polynomial indicating a ^{(R 2 = 0.9989) (y} = 65.113x 2 -2.0715 It was calculated using x-63.578).

Drug
Fenflulamin (FFA) provided by Zogenix International in the laboratory using sodium chloride tablets (catalog number: 07982-100TAB-F) obtained from Sigma-Aldrich (St. Louis, MO, USA). It was dissolved in the prepared sterile saline vehicle.

Statistical analysis Visually analyze seizure behavior videos to determine the incidence (frequency) of AGSz, seizure severity, and S-IRA incidence (frequency) after drug treatment using SPSS software in chi-square, Mann-Whitney. A Whitney U or bivariate t-test was used for statistical comparison with vehicle controls. ED ₅₀ was calculated using SigmaPlot 13 and Microsoft® Excel. The experimental protocols used in these studies have been approved by the Laboratory Animal Care and Use Committee of Southern Illinois University School of Medicine, which follow the guidelines of the National Institute of Health for the care and use of laboratory animals. Measures to minimize animal use and pain and discomfort were included in these procedures.

Dose and time-dependent anticonvulsant effect of FFA on tuning seizures (AGSz) in DBA / 1 mice
Administration of FFA resulted in dose- and time-dependent inhibition of AGSz in DBA / 1 mice. Using the initial test paradigm, susceptibility to AGSz was 20 and 40 mg / kg FFA at 30 minutes (p <0.01 and p <0.001, chi-square test, respectively) when compared to saline-treated controls. It was later significantly reduced (Fig. 1A). For Figure 1A showing the effect of FFA on AGSz, 15 mg / kg (thin vertical bar; n = 9), 20 mg / kg (large dot bar; n = 11) and 40 mg / kg (large diagonal stripe; n =). Systemic intraperitoneal (ip) injection of FFA in 6) significantly reduced the incidence (frequency) of AGSz compared to saline-treated control mice (black bars; n = 21). Was observed. Mice treated with 10 mg / kg (wide downward diagonal bar; n = 11) FFA had no significant effect on the incidence (frequency) of AGSz. [* P <0.05; ** p <0.01;# p <0.001 are each judged by the chi-square test and indicate that there is a statistical difference from the control].

FIG. 1B shows the effect of FFA on the prevention of S-IRA following AGSz in DBA / 1 mice. Significant reduction in incidence (frequency) of S-IRA starting at 30 minutes compared to saline-treated controls (bars as above), administration of 15, 20 and 40 mg / kg intraperitoneal FFA It was seen in the mouse. The incidence (frequency) of S-IRA in mice treated with 10 mg / kg FFA was unaffected. Significant reversion of S-IRA sensitivity in FFA-treated DBA / 1 mice occurred by 72 hours. [* P <0.05; ** p <0.01; # p <0.001 are each judged by the chi-square test and indicate that there is a statistical difference from the control].

The effect of FFA was relatively long-lasting, as it was still significant at 24 hours. The frequency of seizures was no longer significantly different from the control group at 48 hours. Mice treated with 15 mg / kg FFA showed a relatively short duration (<24 hours) and initiation of AGSz inhibition at a later 12 hours (p <0.01, chi-square test). In this study paradigm, a 10 mg / kg dose of FAA was ineffective in blocking AGSz. _{The ED 50} for AGSz inhibition by FFA at 30 minutes was 21.7 mg / kg (Fig. 1C). Figure 1C: 50% effective dose (ED ₅₀ ) is 10,15 relative to the AGSz incidence (frequency) percentage of DBA / 1 mice 30 minutes after FFA treatment, as indicated by the 50% efficacy section. , 20 and 40 mg / kg FFA dose logarithms were determined by plotting.

FFA also significantly reduced AGSz severity in DBA / 1 mice. The AGSz severity reduction data based on the severity score reflected the aforementioned incidence (frequency) data. Early onset (30 minutes) of a significant reduction in AGSz severity was seen in mice treated with 20 or 40 mg / kg FFA, with recovery of maximum seizure severity occurring at 24 and 48 hours, respectively (Fig. 1D). ). As shown in Figure 1D: FFA effectively reduced the severity of AGSz in DBA / 1 mice; starting 30 minutes after 20 and 40 mg / kg FFA (ip) and compared to saline-treated controls. A significant reduction in the median AGSz severity score was observed. For mice receiving 10 and 15 mg / kg FFA, the reduction in severity score was delayed, occurring at 12 hours. Significant recovery of AGSz severity in FFA-treated DBA / 1 mice occurred by 48 hours. [* P <0.05; ** p <0.01; # p <0.001, respectively, as judged by the Mann-Whitney U test, indicating that there is a statistical difference from the control]. AGSz severity reduction in mice treated with 15 mg / kg FFA occurred at a shorter duration and later onset at 12 hours, similar to seizure incidence data (Figure 1A). At 10 mg / kg, FFA significantly reduced AGSz severity in DBA / 1 mice (but not seizure incidence / frequency) at 12 hours (p <0.05, Mann-Whitney U test). The effect of 10 mg / kg FFA on AGSz severity disappeared by 24 hours. Inhibition of S-IRA by FFA (Fig. 1B) was found to be consistent with a reduction in the incidence of tonic seizures (Fig. 5). The incidence of S-IRA following AGSz in DBA / 1 mice was significantly reduced 30 minutes after administration by 15-40 mg / kg of FFA (p <0.05, chi-square test). The effect on S-IRA and tonic seizure incidence after a single systemic injection at the 40 mg / kg dose was long-lasting. Tonic AGSz and S-IRA susceptibility returned by 72 hours in mice treated with 40 mg / kg FFA, but 33.3% of these mice continued to show susceptibility to these seizure behaviors for up to 8 days. In contrast, mice receiving 10 mg / kg FFA showed shorter duration and later onset of S-IRA (36.4%) and tonic seizures (54.6%) at 12 hours (p <0.01, chi-square). Squared test). In this study paradigm, 18.2% of mice receiving 10 mg / kg FFA showed S-IRA inhibition after tonic seizures at 12 hours (Figures 1B and 5), but the incidence of this selective S-IRA blocking effect. Was not statistically significant. As shown in FIG. 5, FFA significantly reduced the incidence of tonic seizures, an AGSz phenotype known to lead to S-IRA, in DBA / 1 mice. Saline-treated controls (black bars; n = 21) from 30 minutes after intraperitoneal administration of 20 mg / kg FFA (large dot bar; n = 11) and 40 mg / kg FFA (large lattice; n = 6). ), A significant reduction in the incidence of tonic seizures was observed. This tonic seizure inhibitory effect was delayed and transient in mice treated with 15 mg / kg FFA (thin vertical bar; n = 9). The incidence of tonic seizures in 10 mg / kg FFA (wide downward diagonal bar; n = 11) treated mice was unaffected. A significant return of S-IRA sensitivity between FFA-treated DBA / 1 mice occurred by 72 hours. [* P <0.05; ** p <0.01; # p <0.001; # p <0.001 are each judged by a chi-square test to indicate that there is a statistical difference from the control].

Effect of FFA on 8-hour test protocol Figures 2A-2D show the time course of the selective S-IRA blocking effect of FFA in DBA / 1 mice (8-hour test protocol). The first 24-hour 8-hour study protocol was used in the next group of studies of the effects of 5-20 mg / kg (ip) doses of FFA. A significant reduction in median AGSz severity score (p <0.01, Mann-Whitney U test) was seen at 10-20 mg / kg doses of FFA at 8 hours (Figure 2A), with AGSz severity up to 24 hours. Returned to pre-dose levels, similar to the results of the initial study protocol (Figure 1D). As shown in Figure 2A, FFA reduced AGSz severity in DBA / 1 mice. IP injections of 10 mg / kg FFA (wide downward diagonal bar; n = 10), 15 mg / kg FFA (thin vertical bar; n = 10) and 20 mg / kg FFA (large dot bar; n = 9). Mice showed a significant reduction in median AGSz severity score starting at 8 hours during the time course compared to saline-treated controls (black bars; n = 12). The severity of AGSz remained unaffected in mice treated with 5 mg / kg FFA (thin horizontal bar; n = 9). Significant recovery of AGSz severity occurred by 24 hours in FFA-treated DBA / 1 mice. [** p <0.01;# p <0.001 indicates that there is a statistical difference from the control, Mann-Whitney U test].

As shown in Figure 2B: FFA reduced the incidence of tonic seizures that could result in S-IRA in DBA / 1 mice. The incidence of tonic seizures preceding S-IRA in DBA / 1 was significantly reduced in mice receiving 10-20 mg / kg FFA over 8 hours compared to saline-treated controls (Fig. 2B). ). DBA / 1 mice treated with 10, 15 and 20 mg / kg FFA showed a significant reduction in the incidence of tonic seizures at 8 hours. This effect of FFA was found to reverse by 48 hours. It was observed that the return of susceptibility to tonic seizures occurred between 16 and 48 hours in mice treated with a dose of FFA of 10 to 20 mg / kg. The dose of 5 mg / kg FFA was ineffective for tonic seizures in DBA / 1 mice. [* P <0.05; # p <0.001 are each determined by chi-square test and indicate that there is a statistical difference from the saline-treated control].

FFA prevented S-IRA in DBA / 1 mice. Mice treated with 10-20 mg / kg FFA showed a significant reduction in the incidence of S-IRA starting at 8 hours (Fig. 2C). Starting 8 hours after administration of 10, 15 and 20 mg / kg FFA, a significant reduction in the incidence of S-IRA occurred compared to saline-treated controls. The incidence of S-IRA in mice treated with 5 mg / kg FFA was unaffected. The reduction in the incidence of S-IRA under this paradigm was consistent with a significant reduction in the incidence of tonic AGSz susceptibility (see Figure 2B). Restoration of S-IRA sensitivity between FFA-treated DBA / 1 mice occurred at 48 hours. [* P <0.05; ** p <0.01; # p <0.001 are each judged by the chi-square test and indicate that there is a statistical difference from the control].

Figure 2D shows the selective S-IRA blocking effect of FFA. A significant reduction in the incidence of S-IRA showed tonic AGSz after 15 mg / kg FFA at 16 hours, continued to show tonic seizures, and a significant [# p <0.001, chi-square] of selective inhibition of S-IRA. Squared test] It was found in 100% of the mice (n = 5) that showed the incidence (Figs. 2B to 2D). Restoration of susceptibility to S-IRA after AGSz was seen in these FFA-treated mice by 48 hours.

With reference to FIG. 6, the overall incidence of selective S-IRA inhibition seen in DBA / 1 mice was 70% during these time course studies (FIG. 6). The overall incidence of selective S-IRA inhibition in FFA-treated DBA / 1 mice is shown in Figure 6; 5 mg / kg FFA ip (thin horizontal bar; n = 9), 10 mg / kg FFA ip (wide downwards). Mice treated with the 8-hour test protocol with diagonal bars; n = 10) and 15 mg / kg FFA ip (thin vertical bars; n = 10). [** p <0.01 indicates that there is a statistical difference from the saline-treated control (black bar; n = 12), chi-square test]. Mice treated with 20 mg / kg FFA followed a similar trend, but both S-IRA and tonic seizure inhibition occurred in most of these mice (Figures 2B-2C). The 5 mg / kg dose of FFA was ineffective in blocking any AGSz behavior in DBA / 1 mice.

Figure 3 shows seizures in which selective S-IRA inhibition with 15 mg / kg FFA (n = 10) is defined by the duration of directional reflex loss compared to the last priming study period (before drug administration). It is shown to be associated with a significant reduction in post-suppression (PID) duration mean. [* P <0.05 (bivariate t-test)]. The duration of positive reflex loss after AGSz in DBA / 1 mice is a measure of PID, which is responsible for patient SUDEP. The duration of PID 16 hours after 15 mg / kg FFA (34.6 ± 13.3s) in mice showing selective S-IRA inhibition was significantly reduced compared to the last priming attack (168.6 ± 43.4s) (168.6 ± 43.4s). p <0.05, paired t-test) (Fig. 3).

Figures 4A and 4B show reduction of the incidence of severe seizures and prevention of S-IRA by FFA pretreatment. In subsequent experiments, AGSz was tested in DBA / 1 mice treated with 15 mg / kg FFA i.p., initially at 16 hours. Figure 4A: DBA / 1 mice (n = 73) tested for the first time 16 hours after 15 mg / kg FFA had tonic seizures (68.5%) and S- compared to saline-treated controls (n = 38). It showed a significant reduction in the overall incidence of IRA (21.9%) (Fig. 4A). FIG. 4B shows selective S-IRA inhibition compared to saline-treated controls in DBA / 1 mice (n = 50) who continued to show tonic seizures 16 hours after treatment with 15 mg / kg FFA. Shows a significant incidence (68%) of. [#P <0.001 (chi-square test] (Fig. 4B). Restoration of S-IRA sensitivity (94.5%) in FFA-treated mice occurred at 48 hours, consistent with previous findings (Fig. 2C).

Discussion The study found that FFA administration significantly reduced seizure severity or significantly blocked AGSz susceptibility in DBA / 1 mice in a dose- and time-dependent manner. FFA was also found to significantly reduce the incidence of S-IRA, and selective inhibition of S-IRA was also observed, which did not affect any seizure behavior. These findings suggest that FFA has therapeutic potential for improving seizure control and preventing SUDEP.

This is the first study to investigate the anticonvulsant effect of FFA in mammalian models of epilepsy and SUDEP. FFA reduced the incidence of tonic seizures, considered the most severe type of seizures that often lead to S-IRA, and, depending on the dose, reduced the sensitivity of DBA / 1 mice to AGSz. These effects include a significant reduction in the frequency of seizures observed with additional (adjuvant) FFA therapy in patients with Dravet syndrome, a type of pediatric epilepsy that exhibits a very high incidence of SUDEP, as well as high drug resistance. Match. Clinical trials in patients with Dravet syndrome have shown that additional therapy with drugs that enhance serotonin receptor activation, including FFA, results in a significant reduction in seizure frequency.

The anticonvulsant effect of a single dose of FFA on AGSz in DBA / 1 mice in this study was long-lasting. This finding is consistent with a rat study that demonstrated a central serotonergic effect with a similar FFA dose lasting for 1 week. This persistent effect of FFA may be due in part to its active metabolite, N-FFA. A relatively long-term anticonvulsant effect (finished by 72 hours) has been seen in fluoxetine studies, which is believed to be at least partially mediated by its active metabolite, norfluoxetine. However, the reduction in seizure severity in DBA / 1 mice with a 40 mg / kg dose of FFA is longer, lasting up to 8 days, and the basis for this long duration may require further testing.

DBA / 1 mice show consistent susceptibility to sudden death from S-IRA immediately after AGSz unless resuscitation is provided rapidly. In this study, FFA provided significant dose and time-dependent inhibition of S-IRA and AGSz. A more detailed study of the time course of FFA effects in 8-hour intervals showed that 15 mg / kg of FFA was significantly and selective for S-IRA in 16 hours without blocking any seizure behavior in DBA / 1 mice. It was found to induce inhibition (Fig. 2D). The overall incidence of selective S-IRA inhibition was 70% in mice in this group (Figure 6), and it was also found that 15 mg / kg FFA significantly reduced the duration of PID (Figure 3). ), This may also be important as long-term PID is a major SUDEP risk factor. A significant occurrence of selective S-IRA inhibition was also seen in mice initially tested 16 hours after FFA at 15 mg / kg (Fig. 4B), further confirming the efficacy and time course of efficacy of the drug. Preliminary pharmacokinetic experiments in FFA dose DBA / 1 mice used in this study showed that the plasma level of FFA and the area under the curve were 16 hours after administration of 15 mg / kg, and the area under the curve was a single oral administration of FFA (0.8 mg / kg /). It shows that it was comparable to the level observed in patients with Dravet syndrome after kg). In addition, the dose of 15 mg / kg FFA in adult mice based on body surface area by Reagan-Shaw et al. Is within the clinically effective range for use in patients [1.8 mg / kg / day (pediatric) or 1.2 mg / kg / day ( Adult)] is converted. The FFA doses of the present disclosure are similar to those of the rodent study, which has established the original utility of this drug.

Thus, 16 hours after administration of 15 mg / kg FFA, selective inhibition of S-IRA occurred, but there was no significant change in any seizure behavior in DBA / 1 mice. Thirty minutes after 20-40 mg / kg FFA, a significant reduction in seizure incidence and severity as well as S-IRA susceptibility occurred, which were long-lasting (≧ 48 hours). _{The 50% effective dose (ED 50} ) that significantly reduced AGSz 30 minutes after FFA injection was 21.7 mg / kg.

The present disclosure provides evidence of the effectiveness of FFA for seizures and seizure-induced death in a mammalian SUDEP model. The ability of low FFA doses to selectively block S-IRA suggests the potential usefulness of FFA in the prevention of SUDEP. These results further confirm and extend SUDEP's serotonin hypothesis.

Systemically administered FFA in DBA / 1 mice is effective in preventing S-IRA and exhibits long-lasting and dose-dependent anticonvulsant effects. These findings by FFA, known to enhance central serotonin release, are consistent with those with fluoxetine, which enhances the action of serotonin by selectively blocking reuptake. As mentioned above, death after AGSz in DBA / 1 mice results from respiratory failure. Serotonin usually plays an important regulatory role in mediating state-dependent changes in respiratory stimulation and activity of the brainstem respiratory center. Brainstem raphe nuclei neurons are a major source of brain serotonin, and recent neuroimaging studies have shown that S-IRA in DBA / 1 mice results in significant activity changes in specific raphe nuclei. There is. Deletion of central serotonergic neurons resulted in decreased arousal and deficiency of respiratory response to elevated _{CO 2 levels in transgenic rodents.} DBA / 1 mice show a genetic deficiency in serotonin synthesis due to decreased expression of tryptophan hydroxylase 2. Nutrient supplementation with 5-hydroxytryptophan, a precursor of serotonin synthesis, significantly reduced the incidence of AGSz behavior in DBA / 1 mice and blocked S-IRA. In addition, there _{was a significant reduction in 5-HT 2C} and 5-HT _3B receptor expression in DBA / 1 mice, and the action of fluoxetine to block S-IRA in DBA / 1 mice was partially 5-HT ₃ It is mediated by receptors. In addition to confirming our first study in DBA / 1 mice, the findings also extend evidence of anticonvulsant and potential SUDEP-preventing effects that enhance central serotonergic neurotransmission. The importance of serotonin in epilepsy and SUDEP has also been supported by recent studies, and FFA has been shown to be effective in preventing both behavioral and electrorecording epilepsy-like activity in zebrafish models of Dravet syndrome. .. Recent autopsy findings in human SUDEP cases also indicate serotonin abnormalities in the brainstem nuclei, including the raphe nuclei. (Patodia, et al., The ventrolateral medulla and medullary raphe in sudden unexpected death in epilepsy. Brain. Epub 2018 Mar 28). Taken together, these findings suggest the potential usefulness of FFA in the prevention of SUDEP in patients.

In summary, SUDEP prophylaxis and better seizure control are promising new uses for fenfluramine previously marketed for weight loss. The diversion of drugs for other purposes is trusted in many medical disciplines, including epilepsy, for rapid identification and laboratory-to-clinical conversion. Specific brain regions and serotonin receptor types involved in mediating the S-IRA and seizure-blocking effects of FFA can be determined. In addition to the serotonin system, FFA is also known to act on sigma and adrenergic receptors. The role of these actions and the determination of cerebrospinal fluid levels of serotonin and other monoamines may provide insight into the mechanism of FFA effect and the pathogenesis of seizure-induced death. Since chronic addition of FFA has been found to be effective in patients with Dravet syndrome, a detailed study of the effects of continuous treatment will provide further evidence of FFA's ability to prevent anticonvulsants and SUDEP.

Example 2
Use of Serotonin (5-HT) Antagonists to Characterize Fenfluramine Activity in Mouse Models of SUDEP and Dravet Syndrome Recently, several serotonin in mediating the effects of serotonin in the prevention of seizure-induced sudden death The contribution of receptor subtypes was evaluated in the DBA / 1 mouse model of SUDEP. In these studies, fenfluramine, known to enhance the release of serotonin (5-hydroxytryptamine, 5-HT) in the brain, is induced by auditory primary seizures (AGSz) and seizures in DBA / 1 mice. It was found to be effective in blocking respiratory arrest (S-IRA) (data not shown). However, prior to this disclosure, it was unclear whether the effects of fenfluramine were mediated by specific 5-HT receptors. Therefore, as disclosed in the present invention, some 5-HT receptor-specific antagonists are used to investigate the effects of fenfluramine, where the antagonists are fenfluramine-mediated anticonvulsant activity (or any). We determined whether other effects) could be reversed and identified a subset of 5-HT receptors to which fenfluramine binds and acts as agonists.

We evaluated the efficacy of several 5-HT antagonists in reversing the effect of fenfluramine on AGSz in DBA / 1 mice. The 5-HT _1a antagonists 5-HT ₂ , 5-HT ₃ , 5-HT ₄ , 5-HT _5a and 5-HT ₇ receptors were tested and the results are detailed below. Studies are underway to investigate the effects of 5-HT ₆ and 5-HT _{1a / 1b antagonists.}

For these experiments, DBA / 1 mice were used (after undergoing established priming procedures to ensure consistent susceptibility to S-IRA after AGSz) and fen to various 5-HT receptors. The effect of furlamin was evaluated. Seizures were induced using an electric bell and revived using a rodent ventilator (Faingold et al., 2010). Mice were administered FFA (15 mg / kg, i.p.) at least 24 hours after priming and tested for AGSz and S-IRA susceptibility 16 hours later. Thirty minutes prior to AGSz induction, selective 5-HT receptor antagonists or vehicles were administered to assess whether specific receptors contributed to FFA's ability to block S-IRA. Seizure behavior was recorded on videotape, quantified, and statistically compared to vehicle-treated negative controls and FFA-treated positive controls (chi-square test; significance set to p <0.05).

Antagonists Specifically, the antagonists tested were: 5-HT _1A antagonist, WAY100635 (0.1-15 mg / kg); 5-HT ₂ antagonist, ritanserin (10-20 mg / kg); 5-HT ₃ antagonist, ondansetron. (1-3 mg / kg); 5-HT ₄ antagonist, GR125487 (20-60 mg / kg); 5-HT _5A antagonist, SB669551 (10-20 mg / kg); and 5-HT ₇ antagonist, SB269970 (30-40 mg) / kg). Studies are also underway to investigate the effects of 5-HT ₆ and 5-HT _{1a / 1b antagonists.}

RESULTS: In particular, a reversal of FFA-induced S-IRA inhibition was observed after 30 minutes of treatment with _{a 5-HT 4 antagonist (GR125487, 30 mg / kg).} Therefore, GR125487 was effective in inducing significant inhibition of S-IRA inhibition of fenfluramine (see Figures 7 and 8). Interestingly, antagonists of 5-HT ₂ , 5-HT ₄ and 5-HT ₇ receptors may reverse the anticonvulsant effect of FFA on the severity of AGSz, but not its S-IRA blocking effect. found. Antagonists of 5-HT ₂ (20 mg / kg, ritanserin), 5-HT ₄ (30 and 60 mg / kg, GR125487) and 5-HT ₇ (30 mg / kg and 40 mg / kg, SB269970) receptors are severely ill with AGSz. The anti-convulsant effect of FFA on degree could be reversed. A 5-HT _5a antagonist, SB669551, blocked the anticonvulsant effect of FFA at 20 mg / kg. In contrast, 5-HT _1A (WAY100635, 0.1-15 mg / kg) and 5-HT ₃ (ondansetron, 1-3 mg / kg) receptor antagonists were ineffective at any dose tested.

Antagonists of 5-HR _1A , 5-HT ₃ , and receptors do not reverse the effects of fenfluramine, and the effects of fenfluramine on S-IRA and / or AGSz interact with these receptors. It suggests that it is not mediated by. In contrast, 5-HT ₂ , 5-HT _5A , and 5-HT ₇ antagonists (ritanserin, 20 mg / kg; SB669551, 20 mg / kg; and SB269970, 30 mg / kg and 40 mg / kg) have anticonvulsant effects on FFA. It was found to block fenfluramine, suggesting that the anticonvulsant effect of fenfluramine may be mediated by interaction with these receptors. In particular, compound GR125487 was found to partially reverse the anticonvulsant and S-IRA inhibitory effects of fenfluramine, allowing fenfluramine to act specifically as an agonist at the _{5-HT 4 receptor.} I concluded that it turned out.

Therefore, the anticonvulsant effect of FFA on AGSz-induced S-IRA in DBA / 1 mice is mediated, at least in part, by activation of _{5-HT 4 receptors. Expression levels of 5-HT 4} receptors in the brains of DBA / 1 mice are not significantly different from those of normal mice (Faingold et al., 2011). These results are surprising in light of previous studies on receptors that mediate the ability of selective serotonin reuptake inhibitors to reduce seizure severity and block S-IRA, and selective 5- It can only be reversed by HT ₃ antagonists (Faingold et al., 2016).

Agonists that activate specific 5-HT receptors are of interest for future studies in animal models of SUDEP and as a possible preventative measure for human SUDEP. In some embodiments, the 5-HT agonist is a 5-HT ₄ receptor agonist. As disclosed herein, a method for reducing the incidence or severity of a human patient seizure, step administering a therapeutically effective dose of 5-HT ₄ agonist to the patient, and 5-HT ₄ agonists The method comprising stimulating the patient's 5-HT ₄ receptor can reduce the incidence or severity of the patient's seizures. In some embodiments, the 5-HT ₄ agonist is fenfluramine.

Example 3
Determining neurotransmitters that mediate the anticonvulsant and S-IRA blocking effects of fenfluramine in DBA / 1 mice
FFA is effective for significantly and selectively increasing peripheral and phase (ie, during post-seizure suppression) levels of 5-HT, norepinephrine and prolactin, and FFA is effective against AGSz and SUDEP in DBA / 1 mice. Therefore (as mentioned above), testing changes in the levels of these neurotransmitters in the central nervous system may be useful in establishing the mechanism of action of FFA. Monoamines (5-HT, dopamine and norepinephrine), adenosine and prolactin in DBA / 1 mouse plasma and brain at times and at doses of FFA found to be effective in blocking AGSz and S-IRA in DBA / 1 mice Levels are compared to levels of FFA and norfenfluramine and analyzed using liquid chromatography combined with mass spectrometry (LC-MS).

Example 4
Enhanced Effect of FFA on Serotonin Precursors for Hearing Primary Attacks (AGSz) and Attack-Induced Respiratory Stops (S-IRA) in DBA / 1 Mice Fenfluramine Enhances 5-HT Release in the Central Nervous System It works by. Therefore, we will test the enhancing effect of co-administration of the serotonin precursor 5-hydroxytryptophan (5-HTP) with fenfluramine on affecting AGSz and S-IRA in DBA / 1 mice. One goal of these trials is to further reduce the dose of the drug without compromising efficacy.

Example 5
Specific seizure-induced brain dysfunction in DBA / 1 mice with severe hypoxia during S-IRA and SUDEP is mediated by decreased blood flow, resulting in severe hypoxia in separate brain regions Bring (Farrell et al., 2016, 2017). Therefore, we will elucidate the brain regions that experience severe hypoxia and may play a role in the pathogenesis of SUDEP in DBA / 1 mice. These brain regions are pharmacological targets for FFA. Differences between uptake of pimonidazole hydrochloride (Hypoxyprobe ™ kit) after S-IRA and its inhibition by FFA were tested _{to establish localized colocalization of 5-HT 4} and sigma 1a receptors in DBA / 1 mice. Elucidate the brain regions and receptors that mediate the effects of FFA on AGSz and S-IRA.

Example 6
DBA / 1 mice also have effects of fenfluramine on EEG, ECG and respiration between AGSz and S-IRA These tests allow the determination of physiological changes activated by FFA. The effect of fenfluramine on the time course of changes in EEG, EKG and respiratory activity is determined between AGSz and S-IRA and compared to S-IRA inhibition after FFA treatment in DBA / 1 mice.

Example 7
Additional testing First anticonvulsant and S-IRA inhibitory effect of FFA, are 5-HT ₄ receptor antagonists (GR125487), to significantly reverse the anticonvulsant and S-IRA inhibitory effect of FFA in DBA / 1 mouse model because it can be carried out further tests to investigate the anticonvulsant and S-IRA blocking ability of additional 5-HT ₄ receptor agonist. For example, 10-30 mg / kg BIMU8 alone and in combination with FFA will be evaluated for its effect on AGSz and S-IRA (Manzke et al., 2003; Hasebe et al., 2015).

In addition, human clinical trials _{evaluated the effects of 5-HT 4} receptor agonists (eg, fenfluramine) on reducing, ameliorating and / or eliminating seizures and / or S-IRA and / or SUDEP.

In addition, intracerebral microinjection of GR125487 (10, 20 and 40 nmol) will be performed to further investigate the effect of _{fenfluramine or other 5-HT 4 receptor agonists on FFA-like targets in the brain (De).} Deurwaerdere et al., 2002; see Consolo et al., 1994).

Furthermore, 5-HT ₄ receptor antagonists, since significantly reduced the anticonvulsant and S-IRA suppression of FFA, to investigate the role of sigma receptors that mediate their effects. The efficacy of the sigma 1 receptor antagonist NE-100 in reversing the effect of FFA on the incidence of AGSz and S-IRA in DBA / 1 mice will be tested in comparison with the sigma 2 antagonist (YUN252).

Finally, if a sigma receptor antagonist can affect the action of FFA in DBA / 1 mice, a sigma 1 or 2 agonist and a positive allosteric modulator, E1R (10-) against AGSz and S-IRA in DBA / 1 mice. A follow-up study on the effect of 75 mg / kg) will be conducted to further verify this mechanism.

The above description merely shows the principle of the present invention. It will be appreciated by those skilled in the art that, although not explicitly stated or shown herein, the principles of the invention can be embodied and various arrangements within their spirit and scope can be devised. Moreover, the terms of all the examples and conditions listed herein are primarily intended to aid the reader in understanding the principles of the invention and the concepts that contribute to the facilitation of technology by the inventors. It should be interpreted that there are no restrictions on such specific examples and conditions. In addition, all statements herein that describe the principles, aspects, and aspects of the invention, and examples thereof, are intended to include both their structural and functional equivalents. In addition, such equivalents are intended to include both currently known equivalents and future developed equivalents, i.e., any developed element that performs the same function regardless of structure. Therefore, the scope of the invention is not intended to be limited to the exemplary embodiments shown and described herein. Rather, the scope and spirit of the invention is embodied by the appended claims.

These and other purposes, advantages, and features of the present invention will become apparent to those skilled in the art by reading the details of the therapeutic agent and its use, which will be described in more detail below.
[Invention 1001]
A method of reducing the incidence or severity of seizures in human patients.
The stage of administering to the patient a therapeutically effective dose of 5-hydroxytryptamine receptor 4 agonist (5-HT _{4 agonist); and}
A step in which a 5-HT ₄ agonist stimulates a patient's 5-HT ₄ receptor, thereby reducing the incidence or severity of seizures in the patient.
The method described above.
[Invention 1002]
A method of inhibiting respiratory arrest (S-IRA) induced by seizures in human patients.
The stage of administering a therapeutically effective dose of a 5-HT _{4 agonist to the patient; and}
The step of stimulating a 5-HT ₄ agonist with a 5-HT ₄ receptor in the patient, thereby inhibiting the patient's S-IRA.
The method described above.
[Invention 1003]
A method of reducing the average length of post-seizure suppression (PID) periods in human patients.
The stage of administering a therapeutically effective dose of a 5-HT _{4 agonist to the patient; and}
A step in which a 5-HT ₄ agonist stimulates a patient's 5-HT ₄ receptor, thereby inhibiting the patient's PID period.
The method described above.
[Invention 1004]
A method of reducing the probability of seizure-induced epilepsy-induced sudden death in epilepsy (SUDEP) in human patients.
The stage of administering a therapeutically effective dose of a 5-HT _{4 agonist to the patient; and}
The step of stimulating a 5-HT ₄ agonist with a 5-HT ₄ receptor in the patient, thereby reducing the accuracy of SUDEP in the patient.
The method described above.
[Invention 1005]
_{A method of stimulating one or more 5-HT 4} receptors in the brain of a patient diagnosed with possible seizure-induced epilepsy sudden death (SUDEP), in which the patient has a seizure. And the above method
The stage of administering a therapeutically effective dose of a 5-HT _{4 agonist to the patient; and}
A step in which a 5-HT ₄ agonist stimulates a patient's 5-HT ₄ receptor, thereby reducing the patient's likelihood of SUDEP.
The method described above.
[Invention 1006]
5-HT ₄ agonists selected from the group consisting of fenfluramine, BIMU-8, cisapride, mosapride, prucalopride, lenzaprid, RS-67506, tegaserod, zacopride, metoclopramide, and sulpiride, or pharmaceutically acceptable salts thereof. The method according to any one of 1001 to 1005 of the present invention.
[Invention 1007]
The method of any of 1001-1005 of the present invention, wherein the 5-HT _{4 agonist is fenfluramine, or a pharmaceutically acceptable salt thereof.}
[Invention 1008]
The method of any of 1001 to 1007 of the present invention, wherein fenfluramine is administered as an adjunctive therapeutic agent.
[Invention 1009]
The method of the invention 1007 or 1008, wherein the therapeutically effective dose of fenfluramine is selected from the group consisting of 0.2 mg / kg / day to 0.08 mg / kg / day up to a maximum daily dose of 30 mg.
[Invention 1010]
Any of 1001 to 1009 of the present invention, wherein a therapeutically effective dose of fenfluramine is administered in a dosage form selected from the group consisting of oral, injection, transdermal, inhalation, nasal, rectal, vaginal and parenteral. the method of.
[Invention 1011]
The method of any of 1001-1010 of the present invention, wherein a therapeutically effective dose of fenfluramine is administered in oral liquid dosage form.
[Invention 1012]
The method of any of 1001-1011 of the present invention, further comprising administering to the patient an effective dose of stiripentol or a pharmaceutically acceptable salt thereof.
[Invention 1013]
The method of any of 1001-1012 of the present invention, further comprising administering to the patient an effective dose of valproate or a pharmaceutically acceptable salt thereof.
[Invention 1014]
The method of any of 1001-1013 of the present invention, further comprising administering to the patient an effective dose of clobazam or a pharmaceutically acceptable salt thereof.
[Invention 1015]
The method of any of 1001-1014 of the present invention, wherein fenfluramine is the only pharmaceutically active drug administered to a patient.
[Invention 1016]
The method of any of 1001-1015 of the present invention, wherein the 5-HT _{4 agonist is at least one of the following:}
(A) Inactive at 5-HT2B receptor;
(B) Neutral agonist of 5-HT2B receptor; and
(C) 5-HT2B receptor A reverse agonist of 5-HT2B receptor.
[Invention 1017]
The method of any of 1001-1016 of the present invention, wherein the patient exhibits a significantly higher response rate compared to placebo.
[Invention 1018]
The method of any of 1001 to 1017 of the present invention, further comprising repeating administration over a period of days until the patient exhibits a ≥40% reduction in seizure frequency from baseline.
[Invention 1019]
The method of any of 1001-1018 of the present invention, wherein the patient exhibits at least ≥50% reduction in the frequency of seizures.
[Invention 1020]
The method of any of 1001-1019 of the present invention, wherein the patient exhibits at least ≥75% reduction in the frequency of seizures.
[Invention 1021]
The method of any of 1001-1020 of the present invention, wherein the patient exhibits at least ≥90% reduction in the frequency of seizures.
[Invention 1022]
The method of any of 1001 to 1021 of the present invention, wherein the patient does not have any seizures.
[Invention 1023]
The method of any of 1001 to 1022 of the present invention, wherein the patient is alive 2 years after the initial administration of the 5-HT _{4 agonist.}
[1024 of the present invention]
The method of any of 1001-1018 of the present invention, wherein the patient has been diagnosed with epilepsy syndrome selected from the group consisting of Dravet syndrome, Lennox-Gastaut syndrome, Douce syndrome, epileptic spasms, West syndrome, and refractory epilepsy. ..

Claims (24)

A method of reducing the incidence or severity of seizures in human patients.
The stage of administering to the patient a therapeutically effective dose of 5-hydroxytryptamine receptor 4 agonist (5-HT _{4 agonist); and}
The method comprising stimulating a 5-HT ₄ agonist on a 5-HT ₄ receptor in a patient, thereby reducing the incidence or severity of seizures in the patient. A method of inhibiting respiratory arrest (S-IRA) induced by seizures in human patients.
The stage of administering a therapeutically effective dose of a 5-HT _{4 agonist to the patient; and}
The method comprising stimulating a 5-HT ₄ agonist with a 5-HT ₄ receptor in the patient, thereby inhibiting the patient's S-IRA. A method of reducing the average length of post-seizure suppression (PID) periods in human patients.
The stage of administering a therapeutically effective dose of a 5-HT _{4 agonist to the patient; and}
The method comprising stimulating a 5-HT ₄ agonist with a 5-HT ₄ receptor in the patient, thereby inhibiting the patient's PID period. A method of reducing the probability of seizure-induced epilepsy-induced sudden death (SUDEP) in human patients.
The stage of administering a therapeutically effective dose of a 5-HT _{4 agonist to the patient; and}
The method comprising stimulating a 5-HT ₄ agonist with a 5-HT ₄ receptor in the patient, thereby reducing the accuracy of the patient's SUDEP. _{A method of stimulating one or more 5-HT 4} receptors in the brain of a patient diagnosed with possible seizure-induced epilepsy sudden death (SUDEP), in which the patient has a seizure. And the above method
The stage of administering a therapeutically effective dose of a 5-HT _{4 agonist to the patient; and}
The method comprising stimulating a 5-HT ₄ agonist with a 5-HT ₄ receptor in the patient, thereby reducing the likelihood of SUDEP in the patient. 5-HT ₄ agonists selected from the group consisting of fenfluramine, BIMU-8, cisapride, mosapride, prucalopride, lenzaprid, RS-67506, tegaserod, zacopride, metoclopramide, and sulpiride, or pharmaceutically acceptable salts thereof. The method according to any one of claims 1 to 5. The method according to any one of claims 1 to 5, wherein the 5-HT _{4 agonist is fenfluramine, or a pharmaceutically acceptable salt thereof.} The method according to any one of claims 1 to 7, wherein fenfluramine is administered as an adjunctive therapeutic agent. The method of claim 7 or 8, wherein the therapeutically effective dose of fenfluramine is selected from the group consisting of 0.2 mg / kg / day to 0.08 mg / kg / day up to a maximum daily dose of 30 mg. Any of claims 1-9, wherein a therapeutically effective dose of fenfluramine is administered in a dosage form selected from the group consisting of oral, injection, transdermal, inhalation, nasal, rectal, vaginal and parenteral. The method described in paragraph 1. The method according to any one of claims 1 to 10, wherein a therapeutically effective dose of fenfluramine is administered in an oral liquid dosage form. The method of any one of claims 1-11, further comprising administering to the patient an effective dose of stiripentol or a pharmaceutically acceptable salt thereof. The method of any one of claims 1-12, further comprising administering to the patient an effective dose of valproate or a pharmaceutically acceptable salt thereof. The method of any one of claims 1-13, further comprising administering to the patient an effective dose of clobazam or a pharmaceutically acceptable salt thereof. The method of any one of claims 1-14, wherein fenfluramine is the only pharmaceutically active drug administered to the patient. The method of any one of claims 1-15, wherein the 5-HT _{4 agonist is at least one of the following:}
(A) Inactive at 5-HT2B receptor;
(B) Neutral agonist of 5-HT2B receptor; and (c) Reverse agonist of 5-HT2B receptor 5-HT2B receptor. The method of any one of claims 1-16, wherein the patient exhibits a significantly higher response rate compared to placebo. The method of any one of claims 1-17, further comprising the step of repeating the administration over a period of days until the patient shows a ≥40% reduction in seizure frequency from the baseline. The method of any one of claims 1-18, wherein the patient exhibits at least ≥50% reduction in the frequency of seizures. The method of any one of claims 1-19, wherein the patient exhibits at least ≥75% reduction in the frequency of seizures. The method of any one of claims 1-20, wherein the patient exhibits at least ≥90% reduction in the frequency of seizures. The method according to any one of claims 1 to 21, wherein the patient does not have any seizures. The method of any one of claims 1-22, wherein the patient is alive 2 years after the initial administration of the 5-HT _{4 agonist.} One of claims 1-18, wherein the patient has been diagnosed with epilepsy syndrome selected from the group consisting of Dravet syndrome, Lennox-Gastaut syndrome, Douce syndrome, epileptic spasms, West syndrome, and refractory epilepsy. The method described.

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